Review of Medical Necessity Criteria
Goals for Today s Seminar To review medical necessity criteria for children services 2
Definition of Medically Necessary statement of policy A service, item, procedure, or level of care that is necessary for the proper treatment or management of an illness, injury, or disability is one that: 1. Will, or is reasonably expected to, prevent the onset of an illness, condition, injury or disability. 2.Will, or is reasonably expected to, reduce or ameliorate the physical, mental or developmental effects of an illness, condition, injury or disability. 3. Will assist the recipient to achieve or maintain maximum functional capacity in performing daily activities. 3
Three parameters are used to determine the appropriate level of care Severity of Condition Criteria for admission or program participation Appropriate intensity of service Least restrictive and/or intrusive service necessary 4
Severity of Condition What specific clinical condition exists as a result of a present DSM diagnosis? Appropriate intensity of service Does the individual s condition and situation (e.g., behavior, symptoms, psychosocial issues) warrant this level of care (i.e. is it clinically necessary)? Least Restrictive/ Least Intrusive Although BHRS may be the least restrictive, often times is seen as most intrusive 5
The guidelines are divided into five sections: 1. Diagnostic evaluation and documentation 2. Severity Levels and Service Correlates 3. Therapeutic Support Criteria 4. Continued Care 5. Discharge and Service Transition Severity Level is divided into 4 intensity levels moving from Level 1 (least intensive) to level 4 (Highly intensive) The first three sections include the evaluation and documentation criteria for admission to the service. The fourth and fifth are for determining the appropriateness of continuing, tapering, and discontinuing care 6
Diagnostic Evaluation and Documentation: Evaluation indicates: Clinic based treatment is not sufficient Behaviors indicate manageable risk for safety to self/others while in the community The child needs home/ community mental health treatment: Within the family or community based residential setting or In the school setting, or Resulting in limitations in social and community interactions 7
Severity Levels and Service Correlates Level I There is serious and/or persistent impairment of developmental progression and/or psychosocial functioning due to a psychiatric disorder, other than only ID, requiring treatment to alleviate acute existing symptoms or to prevent relapse OR Significant psychosocial stressors and/or medical conditions increase the risk that the child s functioning will decrease for his her developmental level OR Symptoms improve in response to comprehensive treatment at a higher level of care, but child is still in need of direct home/community based treatment OR Requires medication and home/community based monitoring of medications to help the child understand the importance of adhering to the therapy recommended AND 8
Level I The child s behavior is assessed to be manageable in the home/community setting, Child is assessed to be responsive to the implementation of a community based treatment plan in the profession judgment of the appropriate behavioral health professional AND Documented commitment by the primary care givers to the treatment plan The severity and expression of the child s behaviors are such that Continuation with a less intensive level of care can not offer either an expectation of improvement, or prevention of deterioration On-site intervention in the home or community offers a more effective preventive to longer term consequences 9
Level 2 Risk of child harming him/herself or others, or causing destruction to property, is assessed as low AND Must include at least one of the criterion below: Suicidal/ homicidal ideation Impulsivity and/or aggression Psycho-physiological condition Psychomotor retardation or excitation Affect/function impairment Psychosocial functional impairment Thought impairment Cognitive impairment 10
Level 2 Presence of very impaired judgment or functional capacity such that interpersonal skills and/or self maintenance in home/ school/ community is highly compromised AND Behavior is assessed to be manageable in the home/community setting and the degree of risk is assessed to be responsive to and effectively reduced by the implementation of a treatment plan as a result of : The delivery of the professional care required to serve the child s specific treatment occurring on site AND Documented commitment by the primary care givers to the therapeutic plan 11
Level 2: The severity and expression of the child s symptoms are such that Continuation with a less intense level of care can not offer either an expectation of improvement or prevention of deterioration AND On-site intervention in the home or community offers a more effective preventive to longer term consequences 12
Level 3 Severe functional impairment as assessed by a risk of an out-of-home or out-of-school placement. In addition, there may be risk of danger in child harming him/herself, harming others, and/or demonstrated destruction to property AND Must include at least one of the criterion below: Suicidal/homicidal threats or intensive ideation Impulsivity and/or aggression Psycho-physiological condition Psychomotor retardation or excitation Affect/Function impairment Psychosocial functional impairment Thought impairment Cognitive impairment AND/OR Presence of very impaired judgment or functional capacity such that interpersonal skills and/or self is highly compromised AND 13
Level 3 Behavior is assessed to be manageable in the home/community setting and degree of risk is assessed to be responsive to, and effectively reduced by the implementation of a treatment plan AND The severity of the child s symptoms are such that Continuation with a less intense level of care cannot offer either an expectation of improvement AND On-site intervention in the home or community offers a more effective preventive to longer term consequences 14
Level 4 There is severe functional impairment which leads to a high risk of an out-of-home placement or out of school placement. In addition, there may be demonstrated risk of endangerment involving child harming self or others, or destruction to property due to emotional or behavioral problems or mental illness Must include at least one of the criterion below: Suicidal/homicidal threatening behavior or intensive ideation Impulsivity and/or aggression Psycho-physiological condition Psychomotor retardation or excitation Affect/function impairment Psychosocial function impairment Thought impairment Cognitive impairment 15
Presence of very impaired judgment or functional capacity and mental level such that interpersonal skills and/or self maintenance is severely compromised AND Behavior is assessed to be manageable in the home/community setting and effectively reduced by the implementation of a treatment plan with Delivery of professional care AND Documented commitment by the primary care givers to the therapeutic plan AND A safety plan AND The severity and expression of the child s symptoms are such that Continuation with a less intensive level of care can not offer either an expectation of improvement or prevention of deterioration AND On-site intervention in the home or community offers a more effective preventive to longer term consequences 16
Support Criteria The on-site clinical expertise necessary must be available as appropriate to the severity of symptoms or behaviors. There must be family commitment to the treatment process of the child or adolescent The treatment must support community integrative objectives including development of the child/adolescent s network of personal, family and community support 17
Continued Care Child must be reevaluated and continue to meet criteria for admission AND Child shows Measured improvement and/or begins to demonstrate alternative/replacement behaviors Increased or continued behavioral disturbance with continued expectation for improvement AND Treatment plan addressing the behavior within the context of the psychosocial stressors/events AND Interagency service plan recommends continuation of care 18
Discharge and Service Transition Prescriber, with the interagency team, determines that home/community service: Results in treatment goal attainment such that no additional home/community services are necessary and discharge occurs. OR Should be maintained at current level, reduced hours, or increased hours Ceases to be effective, requiring reassessment of services and alternative planning OR Interferes with the development of a service independent lifestyle, requiring reassessment of the treatment plan 19