The medical necessity criteria outlined in this guideline for each level of care relating to employee assistance program in the outpatient setting include four categories; Severity of Illness, Intensity of Service, Continued Stay, and Discharge Criteria. Severity of Illness criteria includes descriptions of the Covered Individual's condition and circumstances. Intensity of Service criteria describes the services being provided and these criteria must be met for admission and continued stay. For continued authorization of the requested service, Continued Stay criteria must be met along with Severity of Illness criteria.
This document addresses Employee Assistance Program (EAP) Outpatient Treatment Criteria and these criteria apply only to California DMHC Regulated Business.
Please see the following related document(s) for additional information:
To qualify, the Covered Individual is requesting help with problems that are affecting their work and/or personal life. All services must meet the definition of medical necessity in the Covered Individual's plan document.
Severity of Illness (SI)
Must have all of the following:
- The focus of treatment is symptom resolution, mood and/or behavior stabilization that is amenable to improvement with brief counseling within the model of their plan; AND
- The Covered Individual's problems and/or symptoms do not indicate that they are in imminent need of hospital care due to being a danger to self or others or because they are gravely disabled or are in need of medically supervised detoxification.
Intensity of Service (IS)
Must have all of the following to qualify:
- Assessment is completed which includes identification of specific problems and/or symptoms and impairment which are affecting the Covered Individual in their work and/or personal life. This should always include a substance abuse assessment and general risk assessment; AND
- If appropriate short-term, problem-focused counseling is attempted to resolve the presenting complaint or identified issues; AND
- Relevant community resources assessed and recommended as appropriate; AND
- When long-term counseling is indicated, referrals are provided and transfer of care is appropriately coordinated.
Continued Stay Criteria (CS)
Must have all of the following to qualify:
- Must continue to meet "SI/IS" Criteria and have the following to qualify; AND
- Progress in relation to specific problems and/or symptoms, behaviors and impairments is evident and such as can be resolved within the brief counseling model of their plan.
Discharge Criteria (DC)
Must have one (1) of the following to qualify:
- The problems and/or symptoms that originally brought the Covered Individual/family into treatment are improved to the extent that their work and/or personal life are no longer adversely affected; OR
- Despite attempts at intervention the Covered Individual's problems and/or symptoms appear pervasive, indicating a need for traditional psychotherapy or some other, more intensive service, as opposed to brief counseling and care of the Covered Individual is transferred to another provider within their health plan network; OR
- The Covered Individual is linked to appropriate community resources.
Not Medically Necessary:
Employee assistance program outpatient treatment is considered not medically necessary when the above criteria are not met.
Coding edits for medical necessity review are not implemented for this guideline. Where a more specific policy or guideline exists, that document will take precedence and may include specific coding edits and/or instructions. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.
EAP outpatient treatment should not be primarily for the avoidance of incarceration of the Covered Individual or to satisfy a programmatic length of stay (refers to a pre-determine number of days or visits for a program's length instead of an individualized determination of how long a member needs to be in that program). There should be a reasonable expectation that the Covered Individual's illness, condition, or level of functioning will be stabilized, improved, or maintained through treatment known to be effective for the Covered Individual's illness.
It is noted that there is variation in the availability of services in different geographic and regional areas. If an indicated service is not available within a Covered Individual's community at the level of service indicated by the criteria, authorization may be given for those services at the next highest available level.
In some geographical areas, state regulations allow non-physicians to treat Covered Individuals at inpatient facilities. In these guidelines, such non-physicians with prescriptive authority who are operating within the scope of their license may be substituted where the criteria specifies a physician.
Outpatient Treatment: Outpatient treatment is a level of care in which a mental health professional licensed to practice independently provides care to individuals in an outpatient setting, whether to the Covered Individual individually, in family therapy, or in a group modality.
Peer Reviewed Publications:
- Kahn, DA, Carpenter D, Docherty JP, Frances A. (1996): The expert consensus guideline series: treatment of bipolar disorder. J Clin Psychiatry, 57 (Suppl 12A).
- McEvoy JP, Scheifler PL, Frances A. Treatment of schizophrenia 1999. The expert consensus guideline series. J Clin Psychiatry. 1999; 60 Suppl 11:3-80.
Government Agency, Medical Society, and Other Authoritative Publications:
- American Academy of Child & Adolescent Psychiatry. Practice Parameters. Available at: http://www.aacap.org/cs/root/member_information/practice_information/practice_parameters/practice_parameters. Accessed on April 26, 2013.
- American Psychiatric Association. Clinical Practice Guidelines. Available at: http://www.psych.org/practice/clinical-practice-guidelines. Accessed on April 26, 2013.
- American Society of Addiction Medicine Treatment. Available at: http://www.asam.org/research-treatment/treatment. Accessed on April 26, 2013.
- Center for Substance Abuse Treatment. Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs. Treatment Improvement Protocol (TIP) Series 43. DHHS Publication No. (SMA) 05-4048. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2005.
- Center for Substance Abuse Treatment. Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction. Treatment Improvement Protocol (TIP) Series 40. DHHS Publication No. (SMA) 07-3939. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2004.
- Depression in Primary Care: Detection and Diagnosis. Volume 1. Detection and Diagnosis Clinical Guideline Number 5. AHCPR Publication No. 93-0550: April 1993.
- Fishman MJ, Shulman GD, Mee-Lee D, et al. ASAM patient placement criteria: supplement on pharmacotherapies for alcohol use disorders. 1st ed. Philadelphia: Lippincott Williams & Wilkins. 2010.
- Hoffman NG, Mee-Lee D, Halikas JA. Patient placement criteria for the treatment of psychoactive substance use disorders. Chevy Chase: American Society of Addiction Medicine. 2001.
- Manual of Psychiatric Peer Review (1974). American Psychiatric Association.
- Mattson M. Manual of psychiatric quality assurance: American Psychiatric Association committee on quality assurance. 1st ed. Arlington: American Psychiatric Publishing. 1992.
- Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment. Intensive outpatient treatment for alcohol and other drug abuse. 1994. DHHS Publication No. (SMA) 94B2077.
- Treatment of Major Depression. Volume 2. Treatment of Major Depression Clinical Practice Guideline Number 5. AHCPR Publication No. 93-0551: April 1993.
- Weiner RD. Manual of psychiatric quality assurance. 1st ed. Arlington: American Psychiatric Publishing. 1992. Electroconvulsive therapy guidelines and criteria.
- Weiner RD. Practice of electroconvulsive therapy: recommendations for treatment, training, and privileging (A task force report of the American Psychiatric Association). 2nd ed. Arlington: American Psychiatric Publishing. 2001.
Employee Assistance Program
|New||08/08/2013||Medical Policy & Technology Assessment Committee (MPTAC) review.|
|New||07/26/2013||Behavioral Health Subcommittee review. Initial document development. Updated References. The Behavioral Health Medical Necessity Criteria effective January 1, 2013 was split apart into specific subject matter clinical UM guidelines.|