General — Psychiatric Facilities for Individuals Under Age 21
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Governs Medicaid coverage, conditions of participation, certification, treatment planning, utilization review, and payment for inpatient psychiatric hospitals and Psychiatric Residential Treatment Facilities (PRTFs) for recipients under age 21 in Alabama.
No material clinical or coverage changes in this revision.
Coverage Criteria for Inpatient and PRTF Services
General Coverage
Covered when ALL of the following are met
See Rule 560-X-41-.01
Active Treatment Criteria
Active treatment covered when ALL of the following are met
See Rule 560-X-41-.06
Certification of Need
Certification of Need — required conditions
See Rule 560-X-41-.04
Inpatient Review/Admission Criteria
Inpatient Admission Criteria — patient must meet at least one
See Rule 560-X-41-.09(2) and (e)
Admission (Inpatient/PRTF) Criteria
Covered when ONE OR MORE of the admission criteria are met and inpatient/residential setting is required for active treatment
See Rules 560-X-41-.09 and 560-X-41-.13(2)
Continued Stay Criteria
Continued stay/recertification requires documented ongoing need and active treatment
See Rules 560-X-41-.09(4), 560-X-41-.11, and 560-X-41-.14
PRTF Certification of Need
Certification for PRTF admissions
See Rule 560-X-41-.13(1)-(5)
See Rule 560-X-41-.13(6)-(8)
Therapeutic visits away from the psychiatric hospital that exceed three days in duration are not covered and may not be billed to Medicaid. This rule applies specifically to therapeutic visits from an inpatient psychiatric hospital to home, relatives, or friends; such visits must be certified as medically necessary by the attending physician and, if longer than three days, are nonpayable and cannot be submitted for Medicaid reimbursement.
Providers must not send bills to Medicaid recipients for amounts in excess of Medicaid payment. Providers may not bill the recipient for the difference between charges billed and the amount paid by Medicaid; they must accept Medicaid payment as payment in full. Providers may bill recipients only for the allowable copay, for services not covered by Medicaid, or when benefits have been exhausted. Providers may, however, send a notice marked clearly as "THIS IS NOT A BILL" to inform recipients of outstanding claims while pursuing resolution with the fiscal agent or Medicaid.
For non-emergency admissions of Medicaid recipients, certification of need (PSY-2 form) must be completed prior to admission. If the required certification is completed after admission, payment cannot be made for the period before the certification date. This requirement is enforced when the certifying team determines ambulatory resources are insufficient, inpatient services under physician direction are required, and services are expected to improve or prevent regression.
Admissions that do not require psychiatric services that can only be provided on an inpatient basis, or admissions that lack documentation demonstrating medical necessity as required by the Psychiatric Admission form, may be deemed not medically necessary. For Medicaid recipients the attending physician must sign the Psychiatric Admission form documenting admitting diagnosis, events leading to hospitalization, relevant history, current medications, physician orders, presenting signs/symptoms, history and physical, mental/physical capacity, prognosis, and plan of care; failure to provide this documentation may jeopardize payment.
Diagnosis and Coding Requirements
| 290-316 | ICD-9 diagnosis range (dates services prior and up to September 30, 2015) |
| F01.50-F69 | ICD-10 diagnosis range (dates of services October 1, 2015 and forward) |
| F80.0-F99 | ICD-10 diagnosis range (dates of services October 1, 2015 and forward) |
| G44.209 | ICD-10 code listed in policy |
| H93.25 | ICD-10 code listed in policy |
| R37 | ICD-10 code listed in policy |
| R45.1-R45.2 | ICD-10 codes listed in policy |
| R45.5-R45.82 | ICD-10 codes listed in policy |
| R480 | ICD-10 code listed in policy |
| Z87.890 | ICD-10 code listed in policy |
| ICD-9 290-316 | Diagnosis range for dates of service prior to and up to September 30, 2015 |
| ICD-10 F01.50 - F69 | Diagnosis range for dates of service October 1, 2015 and forward (part) |
| ICD-10 F80.0-F99 | Diagnosis range for dates of service October 1, 2015 and forward (part) |
| ICD-10 G44.209 | Included diagnosis code |
| ICD-10 H93.25 | Included diagnosis code |
| ICD-10 R37 | Included diagnosis code |
| ICD-10 R45.1-R45.2 | Included diagnosis codes |
| ICD-10 R45.5-R45.82 | Included diagnosis codes |
| ICD-10 R48.0 | Included diagnosis code (R480 shown in document) |
| ICD-10 Z87.890 | Included diagnosis code |
Provider Responsibilities, Documentation & Timing
Certification of Need (PSY-2) required before non-emergency admission
Complete PSY-2 (Certification of Need) prior to any non-emergency inpatient admission for a Medicaid recipient; if the certification is completed after admission, payment cannot be made for the period prior to the date the certification is completed.
- PSY-2 form is the Certification of Need for inpatient hospital services.
- Certification must be made by an independent team for non-emergency admissions.
PRTF elective admissions: independent-team certification required (form #370)
For elective/non-emergency PRTF admissions of individuals who are Medicaid-eligible at admission, an independent team (including a physician with competence in diagnosis/treatment) must complete Certification of Need (form #370) no more than 30 days prior to admission and file it in the medical record.
- Form #370 (Certification of Need for Services: Non-Emergency Admission) must be completed and filed in the recipient's medical record.
- Independent team must include a physician and have competence in diagnosis/treatment (preferably child psychiatry) and knowledge of the individual.
Prior outpatient treatment must be documented when relied on for admission
Document either failure of outpatient therapy or that a less restrictive setting is not feasible when admission is based on outpatient-treatment failure or need for inpatient care; at least one admission criterion (including failure of outpatient therapy) must be met for inpatient/PRTF admission.
- Admission criteria include 'failure of outpatient therapy' and 'treatment in a less restrictive environment not feasible due to patient's behavior'.
- Providers must show which admission criterion is met in the record to justify inpatient admission.
Step therapy: not specified
No step therapy protocol is specified in this section.
Required contents of the medical evaluation
Ensure each medical evaluation includes a diagnosis (ICD-9 290-316 for dates prior to Sept 30, 2015; ICD-10 F01.50–F69, F80.0–F99, G44.209, H93.25, R37, R45.1–R45.2, R45.5–R45.82, R48.0, Z87.890 for services Oct 1, 2015 and forward), summary of findings, medical history, functional capacity, prognosis, and a physician recommendation regarding admission or continued care.
- Psychiatric evaluation must be completed within 60 days of admission.
- Physician must recommend admission or continued care as part of the evaluation.
Maintain UR plan and documentation; provide to Medicaid
Maintain a written Utilization Review (UR) plan meeting 42 C.F.R. Sections 456.201–456.245, retain recipient UR information (including Certification of Need and plan of care), and provide the UR plan and revisions to Medicaid for review and approval.
- UR documentation must include the certification of need for service and the plan of care per 42 C.F.R. 456.211.
- Provide a copy of the UR plan and any revisions to Medicaid for review/approval.
PRTF enrollment/recertification: submit certification and yearly attestation
PRTFs must submit a copy of their enrollment certification letter to Medicaid within 45 business days upon enrollment and recertification, and must annually attest to compliance with reporting of serious occurrences and restraint/seclusion requirements on or before July 21.
- Submit certification letter upon enrollment and each recertification within 45 business days.
- Yearly attestation of compliance with 42 CFR, Part 483, Subpart G reporting and restraint/seclusion rules due on or before July 21.
Complete and retain full admission and continued-stay documentation (including Certification forms)
Complete and retain admission documentation in the medical record: admitting diagnosis, events leading to hospitalization, history of psychiatric treatment, current medications, physician orders, presenting signs/symptoms, history and physical, mental/physical capacity, prognosis, and plan of care; Certification of Need forms (#370 elective, #371 emergency) must be filed within required timeframes.
- For Medicaid recipients at admission, the attending physician must sign a Psychiatric Admission form indicating medical necessity.
- For those who apply for Medicaid while in the facility, the Psychiatric Admission form must be signed at the time of application.
- Certification forms must be filed in the medical record to verify compliance.
Late certification for non-emergency admissions disallows payment for prior days
If Certification of Need for a non-emergency admission is completed after admission, Medicaid payment cannot be made for the period prior to the certification date.
Emergency admissions: complete form #371 within 14 days
For emergency admissions, a Certification of Need: Emergency Admission form (#371) must be completed and filed in the medical record within 14 days of admission; failure to meet this requirement may jeopardize payment.
- Interdisciplinary team responsible for the plan of care must complete form #371 within 14 days.
- The team composition for emergency certification is specified (e.g., board-eligible/board-certified psychiatrist or combinations of clinicians).
Therapeutic visit limits and recoupment for overlimits
Therapeutic visits away from the psychiatric hospital are limited to no more than two visits per 60 calendar days with each visit not exceeding three days; payments for visits exceeding these limits will be recouped upon retrospective review.
- The first calendar day begins with the day of admission.
- Visits away from a PRTF are not limited by this policy.
Attending physician must sign Psychiatric Admission form documenting medical necessity
Document medical necessity on the Psychiatric Admission form signed by the attending physician for Medicaid recipients; failure to provide required admission documentation may trigger review and potential denial.
- Psychiatric Admission form must include required elements such as admitting diagnosis, events leading to hospitalization, history of psychiatric treatment, current medications, physician orders, and presenting signs/symptoms.
- Five percent of admissions/concurrent stay charts will be retrospectively reviewed monthly by Medicaid.
Policy Background and Purpose
Inpatient and residential psychiatric treatment for children and adolescents is intended when outpatient resources are insufficient and when services provided under physician direction in an inpatient setting can reasonably be expected to improve the recipient's condition or prevent further regression. Coverage for recipients under age 21 requires that services be certified as medically necessary and that an individualized active treatment plan be developed and implemented no later than 14 days after admission and reviewed at least every 30 days. Active treatment must be delivered by an interdisciplinary team and include clearly stated treatment objectives, integrated therapies, and arrangements for post-discharge coordination with family, school, and community providers.
Key Definitions
Level-of-Care: Inpatient vs PRTF Criteria
Active Treatment & Care Planning
Individualized active treatment plan
See Rule 560-X-41-.06
General active psychiatric treatment
See Rule 560-X-41-.09(3)
Therapeutic Visit Limits
Policy Revision History
Multiple rules in Chapter 41 were amended and became effective March 15, 2021 (filed January 19, 2021), updating provisions across PRTF and inpatient rules including certification and participation requirements.
Amendments to PRTF enrollment/certification rules were filed April 20, 2020 and became effective June 14, 2020.
Amendments filed December 12, 2019 became effective February 14, 2020 (Rule No. 560-X-41-.01 history shows this amendment).
Amendments filed August 27 and June 11, 2015 became effective October 1, 2015, including updates to medical evaluation diagnosis code guidance and active treatment requirements.
Multiple rules (including PRTF certification and continued stay provisions) were filed September 21, 2001 and became effective December 14, 2001, establishing core Chapter 41 provisions.
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