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Coverage criteria policies

Intensive residential treatment services (IRTS) – Minnesota Health Care Programs

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 Intensive Residential Treatment Services.

If a recipient is readmitted to an IRTS within 15 days of discharge, the readmission counts toward the 90-day limit

To request authorization submit the following:

  • Most current diagnostic assessment
  • Current functional assessment
  • Level of Care Utilization System (LOCUS) assessment

Coverage

Intensive Residential Treatment Services (IRTS) is generally covered subject to the indications listed below and per your plan documents:

  • An eligible recipient must be 18 years old or older
  • Recipients may access and receive services from the program outside of the facility when it would benefit the continuity of treatment and transition to the community.
  • Coverage reimbursement is for up to 90 days.
  • Coverage is for treatment days when mental health services are provided; and not days when direct services are not provided.

The following services are covered as part of the program design:

Supervision and direction

Individualized assessment and treatment planning

Crisis assistance, development of health care directives and crisis prevention plans

Nursing services

Interagency case coordination

Transition and discharge planning

Living skills development, including:

  1. Medication self-administration
  2. Healthy living
  3. Household management
  4. Cooking and nutrition
  5. Budgeting and shopping
  6. Using transportation
  7. Employment-related skills

Integrated dual diagnosis treatment (mental health and substance abuse screening and assessment, with a team approach. Assesses treatment readiness, uses motivational interviewing and a non-confrontational approach)

Illness management and recovery (educating about mental illness and treatment including characteristic symptoms and early warning signs of relapse, managing stress and developing relapse prevention plans, developing coping skills and strategies for coping with symptoms, developing social skills to improve effectiveness in interactions across a range of settings and situations, and identifying therapeutic and rehabilitative approaches available to recipients, such as DBT or treatment for OCD)

Family education (services to educate, inform, assist and support family members in mental health illness and treatment, coping mechanisms, medication, community resources)

IRTS Admission Criteria

Admit a recipient to IRTS when a mental health professional determines that all of the following are met:

  1. Has a primary diagnosis of mental illness as determined by a Diagnostic Assessment
  2. Has a completed functional assessment using the domains specified in statute and have three or
  3. more areas of significant impairment in functioning
  4. Has a completed LOCUS assessment where a Level 5 is indicated.
  5. Is reasonably expected to commence or resume illness management and recovery skills or strategies at this level of service
  6. Needs a 24-hour supervised, monitored and focused treatment approach to improve functioning
  7. and avoid relapse that would require a higher level of treatment
  8. Is not responsive to an adequate trial of active treatment at a less intensive level of care
  9. Is at risk of significant functional deterioration if IRTS are not received
  10. Has one or more of the following:
    1. History of two or more inpatient hospitalizations in the past year
    2. Significant independent living instability
    3. Homelessness
    4. Frequent use of mental health and related services yielding poor outcomes in outpatient or
    5. community support treatment

IRTS Continuing Stay Criteria

Continue the recipient’s stay in IRTS when a mental health professional determines the recipient meets all of the following criteria:

  1. The recipient’s mental health needs cannot be met by other less intensive community-based services
  2. The recipient continues to meet admission criteria as evidenced by active psychiatric symptoms and continued functional impairment
  3. Documentation indicates that symptoms are reduced, but discharge criteria have not been met
  4. The essential goals are expected to be accomplished within the requested time frame
  5. Attempts to coordinate care and transition the recipient to other services have been documented

IRTS Discharge Criteria

Discharge a recipient from IRTS when the recipient meets at least one of the following:

  1. No longer meets continuing stay criteria
  2. Has met ITP goals and objectives
  3. Shows evidence of decreased impairment and appropriate, less restrictive community-based alternatives exist
  4. Has symptoms and needs that permit a lesser level of service and adequate supports and services are in place
  5. Is voluntarily involved in his or her ITP and no longer agrees to participate in the IRTS services
  6. Exhibits severe exacerbation of symptoms, decreased functioning, disruptive or dangerous behaviors and requires a more intensive level of service
  7. Has medical or physical health needs that exceed what can be brought into the residential treatment setting
  8. Does not participate in the program despite multiple attempts to engage him or her and to address nonparticipation issues
  9. Does not make progress toward treatment goals and there is no reasonable expectation that progress will be made
  10. Leaves against medical advice for an extended period (determined by written procedures of provider agency)

Definitions

Intensive residential treatment services (IRTS) are time-limited mental health services provided in a residential setting. Recipients of IRTS are in need of structure and assistance from 24-hour mental health staff and at risk of significant functional deterioration if they do not receive these services. IRTS are designed to develop and enhance the following:

  • Psychiatric stability
  • Personal and emotional adjustment
  • Self-sufficiency
  • Skills to live in a more independent setting

Functional Assessment: The purpose and intent of a functional assessment (FA) is:

  1. To use the defined domains to clearly and concisely describe in narrative:
    The individual’s current status within that domain
    The individual’s current level of functioning (strengths of function or impairment of functioning) within that domain
    When applicable and present, making the link to the individual’s mental illness and his or her status and level of functioning within that specific domain
  2. To describe only current status and level of functioning within each domain:
    History of status and functioning (strengths of function or impairment of functioning) may be included on the initial assessment for selected domains if the history and description of past status or past functioning gives context to the individual’s current status or functioning
  3. To assess and identify functional strengths and impairments to:
    Help the individual articulate his or her recovery life vision or goal, service goals, needs and priorities
    Prioritize needs based on the individual’s preferences and posed risk
    Formulate service planning based on the individual’s recovery vision or goal, service goals, priorities and best practice interventions
    Utilize the individual’s strengths of functioning and resources in any domain to build, restore and enhance functioning that is currently impaired in that same or another domain
    Demonstrate medical necessity and establish a “golden thread” documenting that necessity throughout the individual’s service record
    Inform other assessments (i.e., LOCUS)
    Guide the documentation for all services and interventions
    Justify reimbursement or payment for services

Cultural and social mores of the individual recipient must be considered in the assessment of all domains.

LOCUS:

A Level of Care Utilization System (LOCUS) assessment is a level of care tool to help determine the resource intensity needs of individuals who receive adult mental health services.

  • Adult Rehabilitative Mental Health Services (ARMHS) – Level 2 or Level 3
  • Adult day treatment – Level 3
  • Intensive Community Rehabilitative Services (ICRS) – Level 3 or Level 4
  • Assertive Community Treatment (ACT) – Level 4
  • Partial hospitalization – Level 4
  • Intensive Residential Treatment Services (IRTS) – Level 5

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.

Description of procedure code and limitations

Code
Description
Units
Limitations

H0019

Behavioral health; long-term residential (non-medical, non-acute care in a residential treatment program where stay is typically longer than 30 days), without room and board, per diem

1 day

Maximum 90 days.

Readmission within 15 days counts toward 90-day limit

Request authorization for more than 90 days

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

IRTS and Other Concurrent Services and Limitations

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. Minnesota Department of Human Services, Provider Manual, Intensive Residential Treatment Services (IRTS), Revised 09.19.2016.
  2. 2017 Minnesota Statutes 256B.0622; Assertive Community Treatment and Intensive Residential Treatment Services.
  3. 2017 Minnesota Statutes 245.461 to 245.486, Adult Mental Health Act
  4. Minnesota Administrative Rules 9505.0322, Mental Health Case Management Services

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Policy activity

  • 12/07/2018 - Date of origin
  • 12/07/2018 - Effective date

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