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Coverage criteria policies

In-home mental health psychotherapy services

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific 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 in-home mental health psychotherapy services before the first visit, unless ordered by a psychiatrist.

When in-home services are ordered by a psychiatrist, prior authorization is not required until after the 15th visit for the calendar year.

These coverage criteria do not apply to Children’s Therapeutic Support Services (CTSS) which do not need prior authorization.

Coverage

In-home mental health psychotherapy services are generally covered subject to the indications listed below, and per your plan documents.

Indications that are covered

For coverage of in-home mental health psychotherapy services, criteria 1-3 below must be met:

  1. In-home mental health psychotherapy services are based on an in-office Diagnostic Assessment within the past six months performed by a mental health professional who is licensed for independent practice; and
  2. Services must be medically necessary; and
  3. Services are provided by a mental health professional licensed for independent practice.

And at least one of the following criteria must also be met:

  1. The in-home psychotherapy services are part of an inpatient or psychiatric residential discharge treatment plan to allow for a more prompt step-down/transition to outpatient care for continued stabilization.
  2. The member has a complex medical condition such as quadriplegia, morbid obesity, complicated pregnancy requiring bed rest or a behavioral health condition such as agoraphobia that renders the member homebound.
  3. The member is at risk for psychiatric hospitalization or psychiatric residential treatment (due to self-injurious behavior or recent suicidal ideation or intent to injure another).
  4. The member has had prior psychiatric inpatient care within the last twenty-four (24) months.
  5. A psychiatrist treating this member has an order with clinical instructions and goals for the services to take place in the member’s home.

Indications that are not covered

In-home mental health psychotherapy services are not covered for any additional indications not listed above.

Definitions

In-Home Mental Health Psychotherapy Services: Individual and family psychotherapy services provided in a member’s home rather than in an office setting. In-home therapy should be of a short duration with the goal of getting the member ready for office-based work.

Diagnostic Assessment: A diagnostic assessment is a written evaluation conducted by a mental health professional to determine whether a child, youth or adult has a mental health disorder. The mental health professional conducts interviews to gather information about their life situation, such as:

  • Effects of symptoms on functioning in home, school/work and community
  • Onset, frequency, duration and severity of current symptoms
  • History of current mental health problem (developmental incidents, strengths, stressors, etc.)
  • Relevant family and social history
  • Functional impairment
  • Strength and resources

During the interview, the mental health clinician will also examine their general behavior, motor activity, speech, alertness, mood and cognitive functioning. The clinician must ask enough questions to decide if additional data is needed to determine whether or not the symptoms are severe enough to be diagnosed with a specific disorder.

After the interview, the mental health professional determines if there is a mental health diagnosis. This diagnosis then drives the treatment goals, plans and services needed. The diagnostic assessment may reveal the need for referrals for other services, such as psychological testing, physical examination or chemical dependency assessment. It also plays an essential part in determining medical necessity and eligibility for specific services that are developmentally and culturally appropriate.

Homebound: describes a member who is unable to leave home without considerable effort due to a medical or behavioral health condition. For example, a member is considered to be homebound, when the member, due to his/her medical or behavioral health condition, is unable to go to work, school, or daycare; or is unable to go grocery shopping, run errands or attend outpatient appointments. A member’s inability to drive, or lack of transportation, does not qualify the member for homebound status

Mental Health Professional: A mental health professional is licensed by the applicable State Board for independent mental health practice.

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

Description

90791

Psychiatric diagnostic evaluation

90832

Psychotherapy, 30 minutes

90834

Psychotherapy, 45 minutes

90837

Psychotherapy, 60 minutes

90846

Family psychotherapy (without the patient present)

90847

Family psychotherapy (conjoint psychotherapy) (with patient present)

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.

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Policy activity

  • 10/25/2012 - Date of origin
  • 10/01/2017 - Effective date
Review date
  • 06/2018
Revision date
  • 09/12/2017

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