Clinical UM Guideline
|Subject:||Psychosocial Rehabilitation Services|
|Guideline #:||CG-BEH-12||Current Effective Date:||10/06/2015|
|Status:||Revised||Last Review Date:||08/06/2015|
This document addresses psychosocial rehabilitation services (PRS). The medical necessity criteria outlined for PRS 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.
PRS are programs provided to groups of individuals in a nonresidential setting for 2 or more consecutive hours per day. PRS includes assessment, education to teach the member about the diagnosed mental illness and appropriate medications to avoid complication and relapse, opportunities to learn and use independent living skills and to enhance social and interpersonal skills within a supportive and normalizing program structure and environment. Services are more intense than traditional psychiatric services.
Members in PRS 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)
Psychosocial rehabilitation services are considered medically necessary when All of the following are present:
Continued Stay Criteria (CS)
Continued authorization of psychosocial rehabilitation services is considered medically necessary when ALL of 1-5 and 6 or 7 are present:
Not Medically Necessary:
Psychosocial Rehabilitation Services (PRS) 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 psychosocial rehabilitation services. Please contact the member's plan for applicable coding conventions as these may vary.
|H2017||Psychosocial rehabilitation services, per 15 minutes|
|H2018||Psychosocial rehabilitation services, per diem|
|ICD-10 Diagnosis||[For dates of service on or after 10/01/2015]|
|For the following diagnoses, 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|
PRS is sustained treatment that intends to restore a relatively full integration of members suffering from severe persistent mental illness into the community. Services are planned based on individual needs and can include support for medication adherence, treatment of substance abuse, therapy to enhance social and interpersonal skills, family participation and involvement in community activities. Improvement as the result of PRS may be exemplified by achieving member goals, improved social skills, decreased illness symptoms, improved quality of life and obtaining employment or successful school attendance. Randomized trials (RCT's) (Gigantesco, 2006; Shern, 2000; Swildens, 2011) and follow-up studies have not demonstrated consistent impact of PRS on the noted outcome variables with the most consistent finding being the accomplishment of member goals, a critical element in person-centered care.
Individuals suffering from chronic mental illness can benefit from services intended to restore function. A debilitating aspect of serious mental illness or serious emotional disorders is isolation from the larger community as the result of illness symptoms.
PRS should not be primarily for the avoidance of incarceration of the member or to satisfy a programmatic length of stay (refers to a predetermined 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.
Standard components of PRS include:
Standard outcomes of PRS include:
Effective provision of PRS is built on a complete written assessment that identifies and documents the needs for PRS. A person-centered plan should be created that documents goals, objectives and criteria for discharge from PRS 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. The services performed should teach the member about medication management and adherence when medications are prescribed, and if not, the reason and education addressing the lack of medication provided needs to be documented. Training addressing substance use and dependence should be provided when a diagnosis of substance use disorder is present. Opportunities are to be provided for the development of independent living skills and enhancement of social and interpersonal skills. The member's primary care provider or equivalent is to be notified of provision of PRS services, and collaboration on prioritizing treatment should occur. Coordination of care with other clinicians providing care to the member or family members, including psychiatrist/therapist is to be documented. Family participation in treatment should be documented unless there is a contraindication to such participation. If a contraindication exists, rationale for lack of family participation is necessary. Community/natural supports and resources are to be identified and utilized. Skills training should include the development of and communication with support systems, such as community/natural supports, 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 must be provided at the frequency and intensity needs of the member, but are not to exceed limits specified in the member's benefit plan.
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.
Psychosocial Rehabilitation (PRS): An especially intense type of outpatient care consisting of sustained treatment that intends to restore a relatively full integration into the community, exemplified by an ability to work or attend school. Services are planned based on individual needs and can include support for medication adherence, treatment of substance abuse, therapy to enhance social and interpersonal skills, family participation and involvement in community activities.
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 criteria to Discussion/General Information section. Description, Discussion/General Information and Reference sections updated.|
|New||08/14/2014||Medical Policy & Technology Assessment Committee (MPTAC) review.|
|New||08/08/2014||Behavioral Health Subcommittee review. Initial document development.|