Clinical UM Guideline
|Subject:||Mental Health Support Services|
|Guideline #:||CG-BEH-11||Current Effective Date:||10/06/2015|
|Status:||Revised||Last Review Date:||08/06/2015|
This document addresses mental health support services (MHSS). The medical necessity criteria outlined in this guideline for MHSS includes two categories: Severity of Illness and Continued Stay. Severity of Illness criteria includes descriptions of the member's condition and circumstances. For continued authorization of the requested service, Continued Stay criteria must be met, along with Severity of Illness criteria.
MHSS assist members with significant mental illness in maintaining community stability and independence in the most appropriate and least restrictive environment. Services are more intense than traditional psychiatric services. MHSS use individualized training to improve functional skills related to the member's mental health condition, social awareness, appropriate behaviors, activities of daily living, use of community resources, assistance with medication management, nutrition and monitoring of behavioral health and physical health. MHSS are a training service and not companion care. Members in MHSS may also be considered for other services, as consistent with medical necessity.
Note: Please see the following related document(s) for additional information:
Severity of Illness (SI)
Mental health support services are considered medically necessary when ALL of 1-6 and 7 or 8 are present:
Continued Stay Criteria (CS)
Continuation of MHSS is considered medically necessary when ALL of 1-5 and 6 or 7 are present:
Not Medically Necessary:
MHSS are considered not medically necessary when the above criteria are not met.
The following codes for treatments and procedures applicable to this guideline are included below for informational purposes. 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.
Note: The following list of procedure codes are examples only and may not represent all codes being used for mental health support services. Please contact the member's plan for applicable coding conventions as these may vary.
|H0034||Medication training and support, per 15 minutes|
|H0036||Community psychiatric supportive treatment, face-to-face, per 15 minutes|
|H0037||Community psychiatric supportive treatment program, per diem|
|H0046||Mental health services, not otherwise specified [when specified as support services]|
|H2001||Rehabilitation program, per 1/2 day|
|H2015||Comprehensive community support services, per 15 minutes|
|H2016||Comprehensive community support services, per diem|
|ICD-10 Diagnosis||[For dates of service on or after 10/01/2015]|
|For the following diagnoses codes, including but not limited to:|
|F01.50-F99||Mental, behavioral and neurodevelopmental disorders|
|ICD-9 Diagnosis||[For dates of service prior to 10/01/2015]|
|For the following diagnoses, including but not limited to:|
|290.0-319||Mental, behavioral and neurodevelopmental disorders|
MHSS consist of individualized training to improve functional skills related to the member's mental health condition. Services address functional skills, appropriate behaviors, activities of daily living, use of community resources, assistance with medication management, and monitoring of health, nutrition, and physical health.
MHSS should not be primarily for the avoidance of incarceration of the member or to satisfy a programmatic length of stay (refers to a predetermine 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. The population served by MHSS may be burdened with severe and persistent mental illness.
Standard components of MHSS include:
Standard outcomes of MHSS include:
As an example, New Jersey programs are licensed by Department of Human Services (DHS) as Adult Mental Health group homes/supervised apartments per NJAC 10:77 A NJ 10:37A. Member placement and service provisions are compliant with levels of care as described in state-specific law and regulations.
|Adult Mental Health Rehabilitation (AMHR) levels||Risk of harm to self or others||Recovery history||Level of Supervision and Residential support needed||Ability and access to community support|
|Supervised Residence A+||Very High||Very Low||Very High (medication needs to be administered and needs ongoing support with ADLs)||Very low|
|Supervised Residence A||High||Low||High (needs some supervision (reminders) and support with medication administration and with ADLs)||Low|
|Supervised Residence B||Low||High||High (needs some supervision (reminders) and support with medication administration and with ADLs||High|
|Supervised Residence C||Very Low||Very high||Very low – is independent but benefits with weekly check in||Very high|
|Family Care D||Very High||Very Low||Very High (medication needs to be administered and needs ongoing support with ADLs)||Very low|
Certain conditions should be in place for effective provision of MHSS. A comprehensive functional assessment that identifies a need for MHSS should be completed prior to training and at least annually thereafter. A person-centered plan should be created to address goals, objectives and criteria for discharge from MHSS in a manner that reflects member goals, DSM-5/ICD diagnoses listed and the functional assessment. The planning process should be reviewed with the member every 3 months and rewritten no less often than annually. Changes in clinical status (for example, developing new symptoms or findings) should result in reassessment and changes in the treatment plan more often. Training on medication management should be provided when medications are prescribed, and if not, there should be documentation of the reason and education addressing the lack of medication provided. Training addressing substance use/dependence should be provided when a diagnosis of substance use disorder is present or there is a risk for the development of a substance use disorder. Training for monitoring and communicating physical health needs should be provided and there should be documented communication with the primary care provider (PCP), nurse practitioner, advanced practice nurse, or physician assistant as is consistent with licensing standards. Coordination of care with other clinicians providing care to the member or family members, including psychiatrist/therapist, PCP (or equivalent) and other medical professionals should be documented. Family participation in treatment should be documented unless contraindicated. If family participation is not clinically appropriate, the record should give an explanation. Community/natural supports and resources should be identified and utilized, and skills training should include the development of and communication with community/natural supports, including school/work, self-help or diagnosis specific support groups, spiritual/religious, and community recreational activities. Treatment should not duplicate other services being provided for the same reasons/diagnoses. Services should be provided at the frequency and intensity needs of the member in accordance with benefit limits.
Mental Health Support Services (MHSS): Individualized training to improve functional skills related to the member's mental health condition. Services address functional skills, appropriate behaviors, activities of daily living, use of community resources, assistance with medication management, and monitoring of health, nutrition, and physical health. The scope and intensity of services distinguish MHSS from traditional outpatient treatment. In New Jersey, this benefit is called "Adult Mental Health Rehabilitation Services."
Outpatient Treatment: 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.
Severe and Persistent Mental Illness: A mental, behavioral or emotional disorder according to the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders, in members 18 years and older, that results in functional impairment which substantially interferes with or limits one or more major life activities (e.g., maintaining interpersonal relationships, activities of daily living, self-care, employment, recreation) that have occurred within the last year. All of these disorders may have acute episodes as part of the chronic course of the disorder. An organization may also use its state's definition or the definition of another appropriate regulatory authority (National Committee for Quality Assurance [NCQA], 2014).
Peer Reviewed Publications:
Government Agency, Medical Society, and Other Authoritative Publications:
|Revised||08/06/2015||Medical Policy & Technology Assessment Committee (MPTAC) review.|
|Revised||07/31/2015||Behavioral Health Subcommittee review. Multiple clarifications to Medical Necessity Criteria. Moved Intensity of Service from criteria to Discussion/General Information section. Description, Discussion/General Information and Reference sections updated.|
|New||08/08/2014||Behavioral Health Subcommittee review. Initial document development.|