Current through Vol. 42, No. 1, September 16, 2024
(a)
Coverage
for adults. Coverage for adults aged twenty-one (21) to sixty-four (64)
is limited to services in a psychiatric unit of a general hospital or in a
psychiatric hospital (see OAC
317:30-5-95)
. Inpatient psychiatric services must be prior authorized in accordance with
OAC
317:30-5-41.1.
OHCA rules that apply to inpatient psychiatric coverage for adults aged
twenty-one (21) to sixty-four (64) are found in Sections OAC 317:30-5-95.1
through
317:30-5-95.10.
(b)
Medical necessity
criteria for admission of adults aged twenty-one (21) to sixty-four (64) for
psychiatric disorders. An inpatient admission of an adult aged
twenty-one (21) to sixty-four (64) that is attributable to a psychiatric
disorder must meet the terms or conditions contained in (1), (2), (3), (4), one
of (5)(A) to (5)(D), and one of (6)(A) to (6)(C) of this subsection.
(1) A primary diagnosis from the most recent
edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) with
the exception of V-codes, adjustment disorders, and substance related
disorders, accompanied by a detailed description of the symptoms supporting the
diagnosis.
(2) Conditions are
directly attributable to a psychiatric disorder as the primary need for
professional attention (this does not include placement issues, criminal
behavior, and/or status offenses). Adjustment or substance related disorder may
be a secondary diagnosis.
(3) It
has been determined by the OHCA designated agent that the current disabling
symptoms could not have been managed or have not been manageable in a less
intensive treatment program.
(4)
Adult must be medically stable.
(5)
Within the past forty-eight (48) hours, the behaviors present an imminent
life-threatening emergency such as evidenced by:
(A) Specifically described suicide attempts,
suicidal intent, or serious threat by the patient.
(B) Specifically described patterns of
escalating incidents of self-mutilating behaviors.
(C) Specifically described episodes of
unprovoked significant physical aggression and patterns of escalating physical
aggression in intensity and duration.
(D) Specifically described episodes of
incapacitating depression or psychosis that result in an inability to function
or care for basic needs.
(6) Requires secure twenty-four (24) hour
nursing/medical supervision as evidenced by:
(A) Stabilization of acute psychiatric
symptoms.
(B) Needs extensive
treatment under physician direction.
(C) Physiological evidence or expectation of
withdrawal symptoms which require twenty-four (24) hour medical supervision.
(c)
Medical necessity criteria for admission of adults aged twenty-one (21)
to sixty-four (64) for inpatient chemical dependency detoxification /withdrawal
management . An inpatient admission of an adult aged twenty-one (21) to
sixty-four (64) for chemical dependency/ substance use/ detoxification must
meet the terms and conditions contained in (1), (2), (3), and one of (4)(A)
through (D) of this subsection.
(1) Any
psychoactive substance dependency disorder described in the most recent edition
of the Diagnostic and Statistical Manual of Mental Disorders (DSM) with
detailed symptoms supporting the diagnosis and need for medical detoxification,
except for cannabis, nicotine, or caffeine dependencies.
(2) Conditions are directly attributable to a
substance dependency disorder as the primary need for professional attention
(this does not include placement issues, criminal behavior, and/or status
offenses).
(3) It has been
determined by the OHCA designated agent that the current disabling symptoms
could not be managed or have not been manageable in a less intensive treatment
program.
(4) Requires secure
twenty-four (24) hour nursing/medical supervision as evidenced by:
(A) Need for active and aggressive
pharmacological interventions.
(B)
Need for stabilization of acute psychiatric symptoms.
(C) Need extensive treatment under physician
direction.
(D) Physiological
evidence or expectation of withdrawal symptoms which require twenty-four (24)
hour medical supervision.
Added at 17 Ok Reg
3469, eff 8-01-00 (emergency); Added at 18 Ok Reg 1130, eff 5-11-01; Amended at
19 Ok Reg 2138, eff 6-27-02; Amended at 23 Ok Reg 2508, eff
6-25-06
