Clinical UM Guideline


Subject:  Mental Health Support Services
Guideline #:  CG-BEH-11Current Effective Date:  10/06/2015
Status:RevisedLast Review Date:  08/06/2015

Description

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:

Clinical Indications

Medically Necessary:

Severity of Illness (SI)

Mental health support services are considered medically necessary when ALL of 1-6 and 7 or 8 are present:

  1. Interventions will focus on the presenting symptoms and complaints that have led to a decrease in the member's cognitive and behavioral functioning; AND
  2. The member experiences symptoms that meet the diagnostic criteria for a diagnosis from Diagnostic and Statistical Manual of Mental Disorders (DSM-5) or International Classification of Diseases (ICD) for psychiatric outpatient treatment covered by the member's plan; AND
  3. A well-defined clinical rationale is documented that explains why the member would benefit from individualized training in symptom management, adherence to treatment plans, social skills, personal support system, personal hygiene, food preparation, and/or money management consistent with their DSM-5/ICD diagnosis; AND
  4. A history of mental health treatment (for example, psychiatric hospitalization, residential treatment, crisis stabilization, intensive community treatment, etc.); AND
  5. A prescription for anti-psychotic, mood stabilizer, or antidepressant medication within the past 12 months unless there is physician documentation that medications are contraindicated; AND
  6. The member demonstrates motivation for training and is capable of benefiting from training planned; AND
  7. Serious mental illness characterized as a mental, behavioral or emotional disorder defined by current diagnostic criteria (DSM-5/ICD) that results in functional impairment which substantially interferes with or limits one or more major life activities (for example, maintaining interpersonal relationships, activities of daily living, self-care, education, employment, recreation) that have occurred within the last year; OR
  8. A health care provider practicing within the scope of their license has determined that the member experiences severe mental illness resulting in severe and recurrent disability that produces functional limitations in major life activities such as maintaining interpersonal relationships, activities of daily living, self-care, education, employment, and/or recreation AND these limitations require individualized training to achieve and maintain independent living in the community.

Continued Stay Criteria (CS)

Continuation of MHSS is considered medically necessary when ALL of 1-5 and 6 or 7 are present:

  1. The member continues to meet the Severity of Illness criteria; AND
  2. Documentation of member's participation and engagement in services; AND
  3. The goals of MHSS are not primarily for providing support, targets are not primarily functioning that is either chronic and not likely to improve with the type of training being used, or primarily self-improvement; AND
  4. Functional impairment of at least moderate degree as evidenced by report of specific domains are still present related to the DSM-5/ICD diagnosis listed and likely to improve with continued training; AND
  5. Skills have not been acquired where sustained improvement is not likely, and the purpose of continued training is to prevent relapse or maintain previous achieved progress; AND
  6. Progress with the targeted functioning is documented at the expected pace given the presence of medical/physical conditions, stressors and level of support, as evidenced by adherence with treatment, improving severity of functional impairment, and continued progress is expected for the targeted skills with the training approaches being used; OR
  7. If progress is not documented, either diagnosis has been re-evaluated and changed if appropriate, medication has been re-evaluated and changed if indicated, or MHSS and treatment approach has been re-evaluated and changed if appropriate to include new goals/targets.

Not Medically Necessary:

MHSS are considered not medically necessary when the above criteria are not met.

Coding

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.

HCPCS 
H0034Medication training and support, per 15 minutes
H0036Community psychiatric supportive treatment, face-to-face, per 15 minutes
H0037Community psychiatric supportive treatment program, per diem
H0046Mental health services, not otherwise specified [when specified as support services]
H2001Rehabilitation program, per 1/2 day
H2015Comprehensive community support services, per 15 minutes
H2016Comprehensive 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-F99Mental, 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:
290.0-319Mental, behavioral and neurodevelopmental disorders
  
Discussion/General Information

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) levelsRisk of harm to self or othersRecovery historyLevel of Supervision and Residential support neededAbility and access to community support
Supervised Residence A+Very HighVery LowVery High (medication needs to be administered and needs ongoing support with ADLs)Very low
Supervised Residence AHighLowHigh (needs some supervision (reminders) and support with medication administration  and with ADLs)Low
Supervised Residence BLow HighHigh (needs some supervision (reminders) and support with medication administration  and with ADLsHigh
Supervised Residence CVery LowVery highVery low – is independent but benefits with weekly check inVery high
Family Care DVery HighVery LowVery 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.

Definitions

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).

References

Peer Reviewed Publications:

  1. Bowie CR, McGurk SR, Mausbach B, et al. Combined cognitive remediation and functional skills training for schizophrenia: effects on cognition, functional competence, and real-world behavior. Am J Psychiatry. 2012; 169(7):710-718.
  2. Kurtz MM, Mueser KT. A meta-analysis of controlled research on social skills training for schizophrenia.  J Consult Clin Psychol. 2008; 76(3):491-504.

Government Agency, Medical Society, and Other Authoritative Publications:

  1. Boston University Center of Psychiatric Rehabilitation. A Primer on the Psychiatric Rehabilitation Process. Available at: http://www.bu.edu/cpr/products/books/titles/prprimer.pdf. Accessed on June 1, 2015.
  2. Department of Medical Assistance Services. Mental Health Support Services. Available at: http://www.dmas.virginia.gov/Content_atchs/obh/cmh-trngs5.pptx. Accessed on June 1, 2015.
  3. National Committee for Quality Assurance (NCQA). Definition of severe and persistent mental illness (SPMI). 2014. Available at: http://app04.ncqa.org/faq/FAQReportList.asp?Product=146&PrintReport=Select+Report. Accessed on June 1, 2015.
  4. World Health Organization. International Classification of Functioning, Disability, and Health. Available at: http://www.who.int/classifications/icf/en/. Accessed on June 1, 2015.
History

Status

Date

Action

Revised08/06/2015Medical Policy & Technology Assessment Committee (MPTAC) review.
Revised07/31/2015Behavioral 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.
New08/14/2014MPTAC review.
New08/08/2014Behavioral Health Subcommittee review. Initial document development.