Behavioral Health Day Treatment Criteria Effective 10/15/2024

Date: 09/27/24

Behavioral Health Day Treatment Criteria Effective 10/15/2024

Arizona Complete Health-Complete Care Plan (AzCH-CCP) will require prior authorization for all providers for Behavioral Health Day Programs under procedure codes H2012, H2019, and H2020 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: https://www.azcompletehealth.com/providers/login.html

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

AzCH-CCP Prior Authorization Forms are located on our website www.azcompletehealth.com > 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 for submitting an admission request for this service. Clinical packets are required and should include at minimum:

BH Assessment that identifies symptoms of condition and functional impairments contributing to need for services
ART/CFT meeting notes, as applicable
Service plan with H2012/H2019/H2020 goals
Progress notes
Case management notes
Any other clinical documentation that speaks to the criteria elements

Continued Treatment 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:

Recent documentation that describes the functional impairment and BH symptoms that persist even as the services are rendered
Recent case management notes
Recent ART notes
Updated assessments, as applicable
Updated service plan when goals change, as applicable
Any other clinical documentation that speaks to the criteria

Medical necessity criteria for Behavioral Health Day Programs under procedure codes H2019 and H2020.

Admission Criteria

ALL of the following criteria must be met to confirm the need for admission

Member has a valid behavioral health diagnosis
Services provided under H2019/H2020 are documented in the member’s signed service plan
Member experiences specific daily functional impairment caused by a behavioral health disorder. Functional impairments are documented.
Requested services are required to meet the medical and/or behavioral needs of the member and are needed for reasons other than the convenience of the member or the member’s caregiver
Member experiences mental and/or functional disabilities that negatively affect their integration and stability in the community and quality of life and admission will help to reduce or manage the behaviors that interfere with the member’s ability to function
Services are designed to reduce or eliminate the symptoms or behaviors resulting from the member’s condition that prevent the member from functioning at his/her best functional level.
The focus of the intervention is to improve the member’s health and well-being using cognitive, behavioral, or social interventions designed to ameliorate specific diagnosis-related problems.

Continued Stay Criteria

ALL of the following criteria must be met to confirm the need for Continued Stay.

The member continues to meet admission guidelines and medical necessity for Therapeutic Behavioral Service
The member does not require a more intensive level of service nor is a less intensive level of care more appropriate
There is reasonable likelihood of substantial benefits as demonstrated by objective behavioral measurements of improvement in functional areas
The member is making progress towards treatment/rehabilitation goals
The member’s service plan continues to reflect current and active treatment goals for H2019/H2020 services

Discharge Criteria

The member has met their treatment plan goals and objectives
The precipitating condition and relapse potential is stabilized such that the member’s condition can be managed without professional external supports and interventions.
The member has alternative support systems secured to help them maintain stability in the communies.

Medical necessity criteria for Behavioral Health Day Programs under procedure codes H2012.

DAY TREATMENT PROGRAM,

Admission, Week 1 (Must meet ALL:

Housing

o Homeless, must meet ≥ 1:

Unable to obtain safe living residence
Unable to remain in safe living environment despite placement within last 6 months

o Residing in family or friend's residence or supervised living and unable to engage in community activity without supervision

o Transitioning from a controlled environment and lacks skills to reintegrate into the communiy

Planned intervention, must meet both:

o Daily groups

o Individualized goal-directed treatment plan

Symptom stable but persistent despite therapeutic or pharmacologic intervention, must meet ≥ 1:

o Delusions

o Depersonalization

o Derealization

o Disorganized behavior

o Disorganized thinking or speech

o Exaggerated startle reflex and reacting with aggression or violence

o Hallucinations

o Mild or moderate deficit in intellectual functioning

o Negative psychotic symptoms

o Paranoia causing verbal or physical altercations with others (2)

Transportation available

Unable to function independently within the community, must meet ≥ 1:

o Unable to maintain ADLs and recent change from baseline functioning

o Unable to perform IADLs, ≥1:

Lacks understanding of proper nutrition and negatively impacting co-occurring medical condition
Medication nonadherence leading to 3 or greater admissions to more intensive levels of care within the last 12 months
Role performance, ≥ 1:
- Motivated to obtain employment or volunteer work and lacks skills to obtain without assistance
- Terminated from job or volunteer work and history of previous termination within the last year
Unable to identify possible safety concerns or ask for help, ≥ 1:
- Poor communication skills
- Poor problem-solving skills
Unable to maintain appropriate social behavior, ≥ 1:
- Responds with anger during feedback or disagreements
- Problematic sexual behavior
- Verbally aggressive or inappropriate
Unable to obtain food independently
Unable to plan or prioritize or structure daily activities and lack of support to provide assistance
Unable to utilize public transportation or drive and lack of support to provide assistance

Episode Week 2-12 (Must meet 1):

·Symptom improving or expected to improve and not clinically stable for discharge (must meet both):

o Clinical findings within last 2 weeks (both must be met):

Functioning (≥ 1 must be met):
- After-hours crisis intervention despite crisis planning
- Arrest
- Housing (≥ 1 must be met:
  - Continued homelessness and in process of completing application
  - Exploring housing options and within 4 weeks of admission
  - High risk of losing housing
  - Loss of housing and referral to shelter
Problematic sexual behavior
Unable to maintain ADLs without staff assistance despite ADL training
Unable to maintain IADLs without staff assistance despite IADL training (≥ 1 must be met):

o Medication nonadherence, ≥1

Inconsistent adherence to medication despite use of filled medication reminder box
- - Inconsistent adherence to medication despit use of filled medication rei
  - Resistant to taking medication
  - Unable to administer pre-filled medication correctly

o Participating in job or volunteer work and continued impairment (≥ 1 must be met):

Absent from work
COnflict with coworkers or customers or manager
Late to work 2 or more times a week
Terminated from employment
Easily frustrated and unable to complete tasks
Highly distractible or short attention span or unable to concentrate on work
Unable to shift focus from one activity or task to the next
Unable to understand or follow instructions

o Poor communication or social skills despite social skill training (≥ 1 must be met:

Interpersonal conflict (≥ 1 must be met):
- Easily frustrated and frequent irrational or angry outbursts
- Verbal hostility or physical altercation
Non-verbal and inconsistent use of established communication aides
Severe social withdrawal despite attempts to engage in interactions with others
Unable to ask for help or support when frustrated

o Unable to care for dependent children or vulnerable adults due to impaired judgment

o Unable to maintain adequate nutritional intake despite nutrition counseling

o Unable to manage finances despite training and conservatorship court hearing schedule within next 2 weeks

Symptom (≥ 1 must be met):

Aggression
Autism spectrum disorder or intellectual disability (≥ 1 must be met:
- Angry outburst due to change in schedule or routine
- Unable to read facial expression or body language with deficit in social interaction
- Unable to reduce or stop stereotypic movements
Co-occurring substance use disorder (must meet both):

o Substance free and high risk of relapse (≥ 1 must gies

- Desceased 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

o Plan established to attend self-help meetings within next week

Delusions
Depersonalization
Derealization
Disorganized behavior
Disorganized speech or thinking
Dissociation
Exaggerated startle reflex
Hallucinations
Hypomania
Negative symptoms of psychosis

Intervention (must meet All):

Daily groups
Discharge planning (≥ 1 must be met):

o Decreased time in program to practice independent living skills

o Engaging in community activities to utilize skills learned and less than 4 weeks since admission

o Increased time spent at job or doing volunteer work

Individualized goal-directed treatment plan (≥ 1 must be met):

o ADL skill training

o IADL skill training

o Leisure skill training

o Social skills training

o Vocational skill training

Progress assessment at least 1 time per day
Psychiatric or medication evaluation at least 1 time per month by a licensed clinical practitioner, Both:

o Assess effectiveness of current medication regimen in treating targeted symptoms

o Assess patient's compliance in taking prescribed medications

Safety plan in place

Episode Week 13-X, Extended Stay (Must meet 1):

Symptom improving or expected to improve and not clinically stable for discharge (both must be met):
Clinical findings within last 2 weeks (both must be met):
- Functioning (≥ 1 must be met):
  - After-hours crisis intervention despite crisis planning
  - Arrest
  - Housing (≥ 1 must be met):

o Continued homelessness and in process of completing application

o High risk of losing housing

o Loss of housing and referral to shelter

Persistent inability to maintain ADLs or perform IADLs and transition within next week (≥ 1 must be met):

o Community support established

o Family or supports willing and able to assist

o Intensive Community-Based Treatment arranged

o Supervised Living arranged

Problematic sexual behavior

Symptom increasing (≥ 1 must be met:

Assaultive
Bipolar disorder or posttraumatic stress disorder or psychosis and symptom increase (≥ 1 must be met):
- Exaggerated startle reflex with potential of harm to self or others
- Hallucinations
- Hypomania
- Paranoia causing physical or verbal altercations

Intervention, All:

Care coordination with treating providers during transition to alternative services
Daily groups
Discharge planning (≥ 1 must be met):

o Awaiting placement within the next week

o Case manager expected to be assigned within next week