Clinical UM Guideline
|Subject:||Employee Assistance Program Outpatient Treatment|
|Guideline #:||CG-BEH-08||Current Effective Date:||10/06/2015|
|Status:||Revised||Last Review Date:||08/06/2015|
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:
To qualify, the member is requesting help with problems that are affecting their work and/or personal life.
Must have all of the following:
Intensity of Service (IS)
Must have all of the following to qualify:
Continued Stay Criteria (CS)
Must have all of the following to qualify:
Discharge Criteria (DC)
Must have one of the following to qualify:
Not Medically Necessary:
EAP 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.
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.
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.
Peer Reviewed Publications:
Government Agency, Medical Society, and Other Authoritative Publications:
Employee Assistance Program
|Reviewed||08/06/2015||Medical Policy & Technology Assessment Committee (MPTAC) review.|
|Reviewed||07/31/2015||Behavioral Health Subcommittee review.|
|Revised||08/08/2014||Behavioral Health Subcommittee review. Clarification to Severity portion of Medical Necessity criteria. Updated Description, Discussion/General Information, and References.|
|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.|