Clinical UM Guideline


Subject:  Employee Assistance Program Outpatient Treatment
Guideline #:  CG-BEH-08Current Effective Date:  10/14/2014
Status:RevisedLast Review Date:  08/14/2014

Description

This document addresses the use of employee assistance programs (EAP) for outpatient treatment. The medical necessity criteria outlined in this document for each level of care relating to EAP in the outpatient setting include four categories; Severity, Intensity of Service, Continued Stay, and Discharge Criteria. Severity criterion includes descriptions of the member'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 criteria. These criteria apply only to California DMHC Regulated Business.

Note: Please see the following related documents for additional information:

Clinical Indications

Medically Necessary:

To qualify, the member is requesting help with problems that are affecting their work and/or personal life.

Severity
Must have all of the following:

  1. The focus of treatment is problem and/or symptom resolution, mood and/or behavior stabilization that is amenable to improvement with brief counseling within the model of their plan; AND
  2. The member'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:

  1. Assessment is completed which includes identification of specific problems and/or symptoms and impairment which are affecting the member in their work and/or personal life. This should always include a substance abuse assessment and general risk assessment; AND
  2. If appropriate short-term, problem-focused counseling is attempted to resolve the presenting complaint or identified issues; AND
  3. Relevant community resources assessed and recommended as appropriate; AND
  4. 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:

  1. Must continue to meet "Severity/IS" Criteria and have the following to qualify; AND
  2. 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 of the following to qualify:

  1. The problems and/or symptoms that originally brought the member/family into treatment are improved to the extent that their work and/or personal life are no longer adversely affected; OR
  2. Despite attempts at intervention the member'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 member is transferred to another provider within their health plan network; OR
  3. The member is linked to appropriate community resources.

Not Medically Necessary:

EAP outpatient treatment is considered not medically necessary when the above criteria are not met.

Coding

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.

Discussion/General Information

EAPs are benefits provided by a member's employer. EAPs serve organizations and their employees in multiple ways, ranging from identifying and resolving personal concerns including health, marital, family, financial, alcohol, drug, legal, emotional, stress, or other personal issues that can affect job performance. EAP services share a focus with medical treatment on identification of problems and/or symptoms and implementation of interventions to address those problems and/or symptoms within the EAP benefit. Chronic problems and symptoms needing additional attention are addressed by referral to appropriate professionals and community resources. 

EAP outpatient treatment should not be primarily for the avoidance of incarceration of the member or to satisfy a programmatic length of stay (refers to a pre-determined 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 member's illness, condition, or level of functioning will be stabilized, improved, or maintained through treatment known to be effective for the member'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 member'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 members 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.

Definitions

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 member individually, in family therapy, or in a group modality.

References

Peer Reviewed Publications:

  1. Frances A Docherty JP, Kahn DA. The expert consensus guideline series: treatment of bipolar disorder. J Clin Psychiatry. 1996; 5(Suppl 12A):1-88.
  2. Goetzel RZ, Schoenman JA, Chapman LS, et al. Strategies for strengthening the evidence base for employee health promotion programs. Am J Health Promot. 2011; 26(1):TAHP1-6, iii.
  3. Jacobson JM, Sacco P. Employee assistance program services for alcohol and other drug problems: implications for increased identification and engagement in treatment. Am J Addict. 2012; 21(5):468-475.
  4. Kaspin LC, Gorman KM, Miller RM. Systematic review of employer-sponsored wellness strategies and their economic and health-related outcomes. Popul Health Manag. 2013; 16(1):14-21.

Government Agency, Medical Society, and Other Authoritative Publications:

  1. American Psychiatric Association. Clinical Practice Guidelines. Available at: http://www.psych.org/practice/clinical-practice-guidelines. Accessed on May 29, 2014.
  2. American Society of Addiction Medicine Treatment. Available at: http://www.asam.org/research-treatment/treatment. Accessed on May 29, 2014.
  3. California Department of Managed Health Care. 2014. Available at: http://wpso.dmhc.ca.gov/regulations/docs/14ccrip.pdf. Accessed on June 4, 2014.
  4. Depression in Primary Care: Detection and Diagnosis. Volume 1. Detection and Diagnosis Clinical Guideline Number 5. AHCPR Publication No. 93-0550: April 1993.
  5. Manual of Psychiatric Peer Review (1974). American Psychiatric Association.
  6. Mattson M. Manual of psychiatric quality assurance: American Psychiatric Association committee on quality assurance. 1st ed. Arlington: American Psychiatric Publishing. 1992.
  7. 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.
  8. Treatment of Major Depression. Volume 2. Treatment of Major Depression Clinical Practice Guideline Number 5. AHCPR Publication No. 93-0551: April 1993.
Index

Employee Assistance Program

History

Status

Date

Action

Revised08/14/2014Medical Policy & Technology Assessment Committee (MPTAC) review.
Revised08/08/2014Behavioral Health Subcommittee review. Clarification to Severity portion of Medical Necessity criteria. Updated Description, Discussion/General Information, and References.
New08/08/2013MPTAC review.
New07/26/2013Behavioral 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.