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Coverage criteria policies

Children’s residential treatment services - Minnesota Health Care Programs

These services may or may not be covered by all HealthPartners plans. Please see your plan documents for your own coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

Prior authorization is required for children’s residential treatment services.

  • Authorization for treatment services from HealthPartners Behavioral Health Department must be obtained prior to admission.
  • Authorization for room and board charges must be obtained from the appropriate county prior to admission and will be coordinated by HealthPartners Behavioral Health Department.

Coverage

  1. Coverage is for a child/adolescent covered under Minnesota Health Care Programs
  2. Coverage is only provided for Minnesota licensed facilities.
  3. Coverage is provided for children/adolescents under 18 who meet the criteria for severe emotional disturbance (SED). Coverage is assessed using the DHS approved assessment tools - DHS developed universal guidelines and the Child and Adolescent Services Intensity Index (CASII).
  4. Coverage is for treatment services (Revenue codes 0911 with HCPCS code H0019) only.

Indications that are covered

Admission Guidelines for Children’s Residential Mental Health Treatment Programs

Must satisfy each of the following:

  1. Based on a diagnostic and functional assessment within the last 180 days, the child/adolescent has a serious and chronic impairment of developmental progression and/or psychosocial functioning (from their baseline) due to a DSM-5 psychiatric disorder with significant impairments in one or more of the following areas:
    1. age-appropriate self-care and self-regulation;
    2. education;
    3. vocation;
    4. family; and/or social/peer relations.
  2. The child/adolescent’s behaviors resulting from such a psychiatric disorder require a supervised, structured, and 24-hour continuous therapeutic milieu for effective treatment to occur.
  3. The necessary level or intensity of supervision, support and treatment cannot effectively and safely be provided in the child/adolescent’s home or community environment at the proposed time of admission.
  4. A residential treatment setting is the least restrictive setting available that is appropriate to the needs and current condition of the child/adolescent.
  5. There is a likelihood that the child/adolescent will benefit from residential mental health treatment.
  6. The child/adolescent is sufficiently stable from a medical and psychiatric standpoint to participate in and benefit from residential treatment. (If not, should be seeking admission to an acute care setting.)
  7. The child/adolescent’s condition has not improved with an adequate trial of, or is clearly inappropriate for, active treatment at a lesser level of care.
  8. The child/adolescent need not have first failed to make progress toward or meet treatment goals in a less restrictive setting.

Guidelines for Authorization of Continued Treatment in Children’s Residential Mental Health Treatment

  1. Individualized treatment plan is completed after 10 days, and updated every 30 days, with the following included:
    1. Treatment goals and strategies are consistent with the child/adolescent’s diagnostic assessment, including a functional assessment, which led to the admission.
    2. The treatment goals are objective and behaviorally specific, measurable and realistically attainable with expected dates to be met.
    3. Co-morbid diagnoses are appropriately addressed.
    4. Discharge criteria, discharge plan and anticipated date of discharge.
  2. The child/adolescent is participating in the program satisfactorily, or any problems with participation are addressed with treatment goals and interventions.
  3. If the child/adolescent is documented with symptoms or a diagnosis that usually benefits from psychotropic medication, either appropriate medication is documented or a referral for a medication evaluation is documented; in addition, coordination of care with the psychiatrist or other prescriber is documented.
  4. If the child/adolescent has demonstrated physically assaultive/aggressive behavior(s), either in the program or outside of the program, this is addressed with specific interventions and treatment goals.
  5. The child/adolescent’s parents or caretakers are documented to be participating in setting goals, are learning to implement or support treatment in the home when appropriate, and they are documented to be involved in discharge planning.
  6. Continuing treatment is necessary to sustain gains made and prevent a regression that would likely lead to readmission.
  7. Evidence of continued potential to benefit from this level of care.
  8. Residential treatment remains the least restrictive available level of care.

Indications that are not covered

  1. The universal admission criteria above are not satisfied.
  2. The CASll does not indicate a level of functioning that would indicate need for placement in children’s residential facility.
  3. The discharge criteria below are met.

Discharge Criteria

  1. Acute care treatment is required due to safety needs or medical or psychiatric instability. (Transfer to acute care inpatient.); or
  2. The child/adolescent has not shown continued improvement or has deteriorated after a reasonable amount of time in the program, even though there have been documented efforts to better engage the child/adolescent and to alter the treatment plan to try to make it more effective. (Assess for transfer to another residential treatment program or intensive community-based alternative.); or
  3. Either:
    1. The child/adolescent’s level of functioning has improved and a less intensive level of care is appropriate; or
    2. The child/adolescent has achieved the discharge goals; and
  4. The child/adolescent is ready for transition to community living, with the child/adolescent’s home as a priority and community-based resources for support and/or treatment at a level of care sufficient to meet the child/adolescent’s needs has been arranged.

Definitions

Children’s mental health residential treatment - is a 24-hour-a-day program. Services are provided under the clinical supervision of a mental health professional in a community setting, other than an acute-care hospital or regional treatment center. Children’s residential treatment is designed to prevent placement in settings that are more intensive, costly or restrictive than necessary and appropriate to meet the child’s needs. It is designed to improve family living and social interaction skills, help the child gain the necessary skills to return to the community, stabilize crisis admissions and work with families throughout the placement to improve the ability of the families to care for children with severe emotion disturbance in the home.

Emotional disturbance: A child with an organic disorder of the brain, or a clinically significant disorder of thought, mood, perception, orientation, memory, or behavior that meets both of the following: Is detailed in a diagnostic code and seriously limits a child’s capacity to function in primary aspects of daily living, such as personal relations, living arrangements, work, school, and recreation

Severe emotional disturbance: A child with severe emotional disturbance refers to children under the age of 18 with a diagnosable mental health problem that severely disrupts their ability to function socially, academically, and emotionally. SED is when a child with emotional disturbance meets one of the following criteria:

  • Has been admitted to inpatient or residential treatment within the last three years or is at risk of being admitted,
  • is a MN resident and receiving inpatient or residential treatment for an emotional disturbance,
  • has been determined by a mental health professional to meet one of the following criteria:
    • Has psychosis or clinical depression,
    • is at risk of harming self or others as a result of emotional disturbance,
    • has psychopathological symptoms as a result of being a victim of physical or sexual abuse or psychic trauma within the past year,
    • has a significantly impaired home, school or community functioning lasting at least one year or presents a risk of lasting at least one year, as a result of emotional disturbance, as determined by a mental health professional

Codes

If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.

Codes

H0019 for the monthly negotiated rate

Rev code 0911

POS code 99

CPT Copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

References

  1. MN Dept. of Human Services, Provider Manual “Children’s Mental Health Residential Treatment Revised 03-05-2013 LINK
  2. 2017 Minnesota Statutes 256B.0945 Services for Children with Severe Emotional Disturbance
  3. 2017 Minnesota Statutes 245.4882 RESIDENTIAL TREATMENT SERVICES.
  4. 2017 Minnesota Statutes 245.4885 SCREENING FOR INPATIENT AND RESIDENTIAL TREATMENT.
  5. 2017 Minnesota Statutes 245.4871 DEFINITIONS.

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Policy activity

  • 01/29/2009 - Date of origin
  • 07/06/2017 - Effective date
Review date
  • 04/2018

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