S9480 Prior Authorization Requirements

Date: 09/27/24

S9480 Prior Authorization Requirements Effective 10/15/2024

Arizona Complete Health-Complete Care Plan (AzCH-CCP) will require prior authorization for all providers for Mental Health Intensive Outpatient Program (IOP) procedure code S9480 effective 10/15/2024. Prior authorization requests for this level of care can be submitted through our secure provider portal (preferred) or via fax starting on 10/1/2024.

Link to portal log on screen.

AzCH-CCP Behavioral Health (BH) Utilization Management (UM) fax: 844-918-1192

AzCH-CCP Prior Authorization Forms are located on our website > For Providers > Pre-Auth Check

Initial Requests:

To support the successful implementation of this prior authorization change, BH UM has outlined below medical necessity criteria and documentation requirements Clinical packets are required and should include at minimum:

Treating physician’s note recommending level of care
Psychiatric notes with medication information, as applicable
Assessment identifying symptoms of the behavioral health condition and functional impairments that contribute to need for this level of care
CFT/ART notes, as applicable
Discharge plan/step down plan
Service plan with IOP goals
Treating/primary diagnosis for this level of care needs to be a mental health diagnosis, not a substance use disorder diagnosis.

Approved prior authorizations can allow up to 30 days of IOP per review cycle.

Continued Stay Requests:

Updated clinical packets are required for requests for continued services and should be submitted 3-5 days prior to a member’s last covered day. These updated clinical packets should include at minimum:

Documentation demonstrating that a behavioral health professional has evaluated and determined at least once per month, or more as clinically warranted, the member still needs a minimum of 6-9 hours of services a week to justify IOP level of care
Current discharge plan/step down plan
Updated service plan when IOP goals change, as applicable
Documentation describing the functional impairment and symptoms that persist due to the mental health diagnosis. Documentation can include but is not limited to:
- Psychiatric progress notes
- Case management notes
- ART/CFT notes
- Individual and/or IOP group therapy notes
- Updated assessment

Included below is the InterQual medical necessity criteria for admission and for continued stay to an Intensive Outpatient Program under code S9480.

S9480 Intensive Outpatient Program

To prior authorize this level of care admission criteria for IOP has 4 areas that must meet

Able to access treatment services
Functional impairment (at least 1 must apply)
Planned Intervention (all must apply)
Symptoms within last week interfering with daily functioning (at least 1 must apply)

Admission Criteria

Admission, Week 1:

Able to access treatment services (must meet)
Functional impairment (must meet ≥ 1 below):
- Moderate in severity and change in baseline within last month (≥ 1 must be met):
  - Eating disorder and difficulty implementing healthy eating principles
  - Impairment in primary role performance (≥ 1 must apply):
    - Chronic absenteeism from school or work
    - Placed on educational or employment performance plan and having difficulty meeting expectations
    - Self-employed and unable to meet work obligations
    - Suspended or placed on leave of absence from work or school
    - Terminated from work
    - Unemployed or retired and unable to structure daytime hours
  - Impairment in social relations (≥ 1 must be met):
    - Alleged perpetrator of abuse within last month
    - Experienced abuse within the last month
    - Arrest or protection order or restraining order due to domestic dispute
    - Increasing interpersonal conflict
    - Increasing social alienation or isolation
    - Problematic sexual behavior
  - Precipitating stressful life event within last 3 months
  - Unable to perform IADLs and recent change from baseline functioning
- Transfer from Inpatient or Residential Treatment Center or Partial Hospitalization Program within last week (both must apply):
  - Impairment in daily functioning
  - Moderate symptoms requiring clinical assessment at least 2 days per week
- Planned intervention (all must apply):
- Can tolerate programming at least 9 contact hours per week
- Individualized goal-directed treatment plan
- Medication reconciliation
- Psychosocial assessment
- Symptom within last week and interfering with daily functioning (must meet ≥ 1 below):
- Anxiety disorder and associated symptom
- Assaultive or threatening within last 24 hours and able to prevent reoccurrence
- Body dysmorphic disorder
- Compulsions
- Co-occurring substance use disorder (≥ 1 must apply):
  - High-risk sexual behaviors
  - Increasing substance use and unable to apply skills to reduce or prevent use
  - Substance free and high risk of relapse (≥ 1 must apply):
    - ·Decreased ability to utilize adequate coping strategies
    - Decreased self-efficacy or motivation to remain abstinent
    - Increase in individual relapse warning signs
    - Loss of positive support system or recovery network
- Depressive disorder or major depressive episode and associated symptom (≥ 1 must apply):
  - Excessive or inappropriate guilt
  - Feelings of worthlessness
  - Hopelessness
  - Impaired ability to make decisions
  - Loss of appetite with weight loss or lack of consistent weight gain
  - Overeating with persistent weight gain
  - Psychomotor agitation or retardation
  - Recurrent thoughts of death
  - Unable to think clearly or concentrate
- Disruptive or impulse-control or conduct disorder and associated symptom (≥ 1 must apply):
  - Bullying or intimidating or threatening others
  - Deliberate or vindictive behavior damages property or harms others
  - Driving at excessive speeds
  - Fire setting to relieve tension without harm to self or others
  - Risky substance use
  - Stalking
  - Stealing
  - Distorted thinking (≥ 1 must be met):
  - Misinterpretation of interactions
  - Paranoia causing verbal or physical altercations with others
  - Eating disorder (≥ 1 must be met):
  - Binge eating 4 or more times weekly and (all of the following must apply):
    - Binge eating a large quantity of food
    - Lack of control while binge eating (≥ 3 must be met):
      - Alone due to embarrassment
      - At a rapid pace
      - Feeling depressed or disgusted or very guilty after binge eating
      - When not physically hungry
  - Marked distress due to binge eating (≥ 1 must apply):
    - Diagnosis of comorbid psychiatric condition
    - Overvaluation of shape or weight
    - Compensatory behaviors 4 or more times weekly and (≥ 1 must apply):
    - Compulsive exercise interferes with daily functioning
    - Purging
  - Excessive preoccupation with eating or weight or body image interferes with IADLs or interpersonal relationships
  - Food rituals interfere with daily functioning
  - Recent and continuing weight loss and weight greater than 85% (0.85) ideal body weight
  - Restricting or refusing food intake at 1 to 2 meals or snacks daily on most days
    - Emotional dysregulation severe (≥ 1 must be met):
    - Angry or impulsive outbursts at least 3 times per week in at least 2 different situations (must meet ≥ 1):
      - Physical outbursts
      - Verbal outbursts
      - Extreme mood lability
- Fire setting history and risk of re-occurrence (≥ 1 must be met):
  - Increased preoccupation
  - Possession of fire setting material
- Gender dysphoria and associated symptoms
- Hair pulling resulting in tissue damage or systemic infection not attributable to medical cause
- Hoarding that causes difficulty in maintaining a safe environment for self or others
- Homicidal thoughts increasing without intent or plan
- Hypomanic symptom (≥ 2 must apply):
  - Decreased need for sleep
  - Distractibility
  - Excessive involvement in activities with potential for negative consequences
  - Flight of ideas
  - Grandiosity
  - Increased talkativeness
  - Inflated self-esteem
  - Pressured speech
- Increasing difficulty resisting urges to harm self
- Non-suicidal self-injury increasing in frequency or intensity
- Obsessions
- Posttraumatic stress disorder and associated symptom
- Psychotic symptom (≥ 1 must apply):
  - Delusions
  - Disorganized speech or thinking
  - Disorganized behavior
  - Hallucinations
  - Negative symptoms
- Skin picking resulting in tissue damage or systemic infection not attributable to medical cause
- Suicidal thoughts increasing without intent or plan

Continued services criteria

Episode Week 2-3, (1 of the following must be met):

Symptom improved and discharge expected today (1 of the following must be met):
- Patient or caregiver demonstrates ability to manage condition and condition does not require daily monitoring (outpatient criteria)
Symptom improving or expected to improve and not clinically stable for discharge, both:
- Finding within last week, both:
  - Functional impairment (must meet ≥ 1 below):
    - Deterioration in care of dependent children or vulnerable adults
    - Difficulty implementing substance free living skills (≥ 1 must apply):
      - Persistent inability to apply effective coping skills in high-risk situations
      - Substance use and continued motivation
      - Unable to ask for help or develop positive supports
      - Unable to disengage from substance abusing peer group
    - Easily frustrated
    - Eating disorder and difficulty implementing health eating principles
    - Increasing social isolation or alienation
    - Interpersonal conflict (≥ 1 must be met):
      - Increasing verbal hostility
      - Accusatory or manipulative
      - Recurrent angry outbursts
      - Problematic sexual behavior
  - Persistent difficulty or decreased productivity at work or school
  - Stalking
  - Unable to concentrate and complete tasks.
  - Symptom (≥ 1 must apply):
  - Anxiety disorder and associated symptom
  - Assaultive or threatening within last 24 hours and able to prevent reoccurrence
  - Compulsions
    - Co-occurring substance use disorder (≥ 1 must be met):
    - High-risk sexual behaviors
    - Increasing substance use and unable to apply skills to reduce or prevent use
      - Substance free and high risk of relapse, ≥ one:
      - Decreased self-efficacy or motivation to remain abstinent
      - Denying or refusing to discuss triggers or cravings
      - Drug glorification
      - Drug-seeking
      - Increased thoughts about using substance
      - Increased cravings or urges to use substance
        Intentionally putting self into triggering situations, ≥ one:
        Going to places they used to drink or use
        Spending time with people who drink or use
  - Not asking for help when needed
  - Overwhelming guilt or remorse or shame
  - Preoccupation with using substances or past substance use and associated experiences
  - Provoking arguments or alienating supports
  - Severe cravings
- Depressive disorder or major depressive episode and associated symptom (≥ 1 musts be met):
  - Early morning awakening, difficulty falling asleep or middle of the night awakening and total hours slept decreasing
  - Excessive or inappropriate guilt
  - Feelings of worthlessness
  - Hopelessness
  - Impaired ability to make decisions
  - Loss of appetite with weight loss or lack of consistent weight gain
  - Overeating with persistent weight gain
  - Psychomotor agitation or retardation
  - Recurrent thoughts of death
  - Unable to think clearly or concentrate
- Disruptive or impulse-control or conduct disorder and associated symptom (≥ 1 must apply):
  - Bullying or intimidating or threatening others
  - Deliberate or vindictive behavior damages property or harms others
  - Driving at excessive speeds
  - Fire setting to relieve tension without harm to self or others
  - Risky substance use
  - Stalking
  - Stealing
- Distorted thinking (≥ 1 must be met):
  - Misinterpretation of interactions
  - Paranoia causing verbal or physical altercations with others
- Eating disorder (≥ 1 must apply):
  - Binge eating when not supervised
  - Body image distortion
  - Cognitive impairment related to inadequate nutritional intake
  - Compulsive exercise interferes with daily functioning
  - Food rituals interfere with daily functioning
  - Intense fear of weight gain or obesity
  - Purging when not supervised
  - Restricting or refusing food when not supervised
  - Use or possession of appetite controlling or weight reducing substance
- Emotional dysregulation severe (≥ 1 must be met):
  - Angry or impulsive outbursts at least 3 times per week in at least 2 different situations, must meet ≥ one:
    - Physical outbursts
    - Verbal outbursts
  - Extreme mood lability
- Fire setting history and risk of re-occurrence (≥ 1 must be met):
  - Increased preoccupation
  - Possession of fire setting material
- Gender dysphoria and associated symptoms
- Hair pulling resulting in tissue damage or systemic infection not attributable to medical cause
- Hoarding that causes difficulty in maintaining a safe environment for self or others
- Hypomanic symptom (≥ 1 must apply):
  - Decreased need for sleep
  - Distractibility
  - Excessive involvement in activities with potential for negative consequences
  - Flight of ideas
  - Grandiosity
  - Increased talkativeness
  - Inflated self-esteem
  - Pressured speech
- Increasing difficulty resisting urges to harm self
- Non-suicidal self-injury increasing in frequency or intensity
- Obsessions
- Posttraumatic stress disorder and associated symptom
- Psychotic symptom (≥ 1 must apply):
  - Delusions
  - Disorganized speech or thinking
  - Disorganized behavior
  - Hallucinations
  - Negative symptoms
- Skin picking resulting in tissue damage or systemic infection not attributable to medical cause
Intervention (all must apply):
- Can tolerate programming at least 9 contact hours per week
- Individualized goal-directed treatment plan
- Skills development training

Episode Week 4-X, Extended Stay (1 of the following must be met):

Symptom improved and discharge expected today (1 of the following must be met):
- Patient or caregiver demonstrates ability to manage condition and condition does not require daily monitoring (outpatient criteria)
Symptom improving or expected to improve and not clinically stable for discharge (both must apply):
- Finding within last week, both:
  - Functional impairment (≥ 1 must be met):
    - ·Deterioration in care of dependent children or vulnerable adults
    - Difficulty implementing substance free living skills (≥ 1 must be met):
      - Persistent inability to apply effective coping skills in high-risk situations
      - Substance use and continued motivation
      - Unable to ask for help or develop positive supports
      - Unable to disengage from substance abusing peer group
    - Easily frustrated
    - Eating disorder and difficulty implementing health eating principles
    - Increasing social isolation or alienation
    - Interpersonal conflict, ≥ one:
      - Increasing verbal hostility
      - Accusatory or manipulative
      - Recurrent angry outbursts
      - Problematic sexual behavior
  - Persistent difficulty or decreased productivity at work or school
  - Stalking
  - Unable to concentrate and complete tasks.
- Symptom, ≥ one:
  - Anxiety disorder and associated symptom
  - Assaultive or threatening within last 24 hours and able to prevent reoccurrence
  - Compulsions
  - Co-occurring substance use disorder (≥ 1 must be met):
    - High-risk sexual behaviors
    - Increasing substance use and unable to apply skills to reduce or prevent use
      - Substance free and high risk of relapse (≥ 1 must be met):
      - Decreased self-efficacy or motivation to remain abstinent
      - Denying or refusing to discuss triggers or cravings
      - Drug glorification
      - Drug-seeking
      - Increased thoughts about using substance
      - Increased cravings or urges to use substance
      - Intentionally putting self into triggering situations (≥ 1 must be met):
        Going to places they used to drink or use
        Spending time with people who drink or use
  - Not asking for help when needed
  - Overwhelming guilt or remorse or shame
  - Preoccupation with using substances or past substance use and associated experiences
  - Provoking arguments or alienating supports
  - Severe cravings
- Depressive disorder or major depressive episode and associated symptom (≥ 1 must be met):
  - Early morning awakening, difficulty falling asleep or middle of the night awakening and total hours slept decreasing
  - Excessive or inappropriate guilt
  - Feelings of worthlessness
  - Hopelessness
  - Impaired ability to make decisions
  - Loss of appetite with weight loss or lack of consistent weight gain
  - Overeating with persistent weight gain
  - Psychomotor agitation or retardation
  - Recurrent thoughts of death
  - Unable to think clearly or concentrate
- Disruptive or impulse-control or conduct disorder and associated symptom (≥ 1 must be met):
  - Bullying or intimidating or threatening others
  - Deliberate or vindictive behavior damages property or harms others
  - Driving at excessive speeds
  - Fire setting to relieve tension without harm to self or others
  - Risky substance use
  - Stalking
  - Stealing
- Distorted thinking (≥ 1 must be met):
  - Misinterpretation of interactions
  - Paranoia causing verbal or physical altercations with others
- Eating disorder (≥ 1 must be met):
  - Binge eating when not supervised
  - Body image distortion
  - Cognitive impairment related to inadequate nutritional intake
  - Compulsive exercise interferes with daily functioning
  - Food rituals interfere with daily functioning
  - Intense fear of weight gain or obesity
  - Purging when not supervised
  - Restricting or refusing food when not supervised
  - Use or possession of appetite controlling or weight reducing substance
- Emotional dysregulation severe (≥ 1 must be met):
  - Angry or impulsive outbursts at least 3 times per week in at least 2 different situations (≥ 1 must be met):
    - Physical outbursts
    - Verbal outbursts
  - Extreme mood lability
- Fire setting history and risk of re-occurrence (≥ 1 must be met):
  - Increased preoccupation
  - Possession of fire setting material
- Gender dysphoria and associated symptoms
- Hair pulling resulting in tissue damage or systemic infection not attributable to medical cause
- Hoarding that causes difficulty in maintaining a safe environment for self or others
- Hypomanic symptom (≥ 1 must be met):
  - Decreased need for sleep
  - Distractibility
  - Excessive involvement in activities with potential for negative consequences
  - Flight of ideas
  - Grandiosity
  - Increased talkativeness
  - Inflated self-esteem
  - Pressured speech
- Increasing difficulty resisting urges to harm self
- Non-suicidal self-injury increasing in frequency or intensity
- Obsessions
- Posttraumatic stress disorder and associated symptom
- Psychotic symptom (≥ 1 must be met):
  - Delusions
  - Disorganized speech or thinking
  - Disorganized behavior
  - Hallucinations
  - Negative symptoms
- Skin picking resulting in tissue damage or systemic infection not attributable to medical cause
Intervention, all:
- Can tolerate programming at least 9 contact hours per week
- Individualized goal-directed treatment plan
- Skills development training

If you have questions on these criteria, please contact your Provider Engagement Specialist who will coordinate with the BH UM team in order to assist you. If you need your assigned Provider Engagement Specialist’s contact information, please email us at AzCHProviderEngagement@azcompletehealth.com.