CurrentAlabama MedicaidPolicy 560-X-41-.01

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.

Policy Summary

PayerAlabama Medicaid

PolicyGeneral — Psychiatric Facilities for Individuals Under Age 21

Policy CodePolicy 560-X-41-.01

Change TypeNo material change

Effective DateMar 15, 2021

Last ReviewMar 15, 2021

Next Review Date

Key ActionComplete Certification of Need (PSY-2 or form #370/#371 as applicable) prior to non-emergency admission or within required timeframe to preserve payment.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

unlimitedInpatient psychiatric days if medically necessary

unlimitedResidential psychiatric treatment days if medically necessary

14 daysPlan of care developed/implemented by

30 days

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CurrentAlabama MedicaidPolicy 560-X-41-.01

General — Psychiatric Facilities for Individuals Under Age 21

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Policy Summary

PayerAlabama Medicaid

PolicyGeneral — Psychiatric Facilities for Individuals Under Age 21

Policy CodePolicy 560-X-41-.01

Change TypeNo material change

Effective DateMar 15, 2021

Last ReviewMar 15, 2021

Next Review Date

Key ActionComplete Certification of Need (PSY-2 or form #370/#371 as applicable) prior to non-emergency admission or within required timeframe to preserve payment.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

unlimitedInpatient psychiatric days if medically necessary

unlimitedResidential psychiatric treatment days if medically necessary

14 daysPlan of care developed/implemented by

30 days

Plan of care review frequency

2/60 daysTherapeutic visits away from hospital limit

per diemPayment basis

Coverage Criteria for Inpatient and PRTF Services

General Coverage

Covered when ALL of the following are met

General coverage conditions: Recipient is under age 21; services are provided under the direction of a physician; facility is an enrolled psychiatric hospital (per Rule 560-X-41-.02) OR a PRTF accredited/certified as specified; services are provided before the recipient reaches age 21 (or until the earlier of no longer required or age 22 if receiving services immediately before age 21); recipient is admitted to and remains in the facility for the course of the hospitalization; and services are certified in writing as necessary per 42 C.F.R. § 441.152.all

See Rule 560-X-41-.01

Active Treatment Criteria

Active treatment covered when ALL of the following are met

Active treatment plan requirements: An individual plan of care is developed and implemented no later than 14 days after admission; the plan is designed to achieve discharge at the earliest possible time; it is based on a comprehensive diagnostic evaluation; developed by an interdisciplinary team in consultation with the recipient and parents/guardians; states treatment objectives and prescribes an integrated program of therapies, activities, and experiences; includes post-discharge coordination with family, school, and community; and the plan is reviewed at least every 30 days.all

See Rule 560-X-41-.06

Certification of Need

Certification of Need — required conditions

Certification team and timing: Certification of need must determine ambulatory community resources are insufficient, proper treatment requires inpatient services under physician direction, and services can reasonably be expected to improve the recipient's condition or prevent regression. The PSY-2 form must be completed. For non-emergency admissions certification must be made prior to admission by an independent team that includes a physician competent in diagnosis/treatment and knowledgeable of the individual's situation; for emergency admissions certification by the responsible plan-of-care team must occur within 14 working days.all

See Rule 560-X-41-.04

Inpatient Review/Admission Criteria

Inpatient Admission Criteria — patient must meet at least one

Admission triggers: At least one of the following: inappropriate performance of activities of daily living (e.g., inappropriate hygiene/grooming, psychomotor agitation or retardation, severe disturbances in appetite or sleep); impaired safety (e.g., inappropriate depressed/agitated mood, suicidal ideation/threat/gesture/attempt, substance abuse, inappropriate behavior requiring intervention, noncompliance with medication or treatment); impaired thought processes (e.g., verbal/behavioral disorganization, thought disorganization, hallucinations, paranoid ideation, phobias, impaired reality testing, bizarre or delusional behavior, disorientation or memory impairment endangering welfare, severe withdrawal or catatonia); or inpatient treatment required due to failure of outpatient therapy, failure of social/family functioning placing patient at increased risk, behavior making less restrictive environment infeasible, need for intensive inpatient evaluation, need for 24-hour skilled and intensive observation, need for evaluation of drug tolerance, or recurrence of psychosis not responding to outpatient treatment.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

Admission criteria: Patient meets at least one of the specified admission criteria (including inappropriate ADL performance, psychomotor changes, severe appetite/sleep disturbance; impaired safety such as suicidal ideation/gesture/attempt, substance abuse, noncompliance; impaired thought process including disorganization, hallucinations, delusions, impaired reality testing; OR need for inpatient care due to failure of outpatient therapy, need for 24-hour skilled observation, recurrence of psychosis not responsive to outpatient care, toxic effects of psychotropic drugs, or positive toxicology with symptoms).at least one

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

Continued stay criteria: Patient must meet at least one continued stay criterion such as active intervention by at least one member of the interdisciplinary team for an unresolved problem on the treatment plan; medication changes or administration of PRN medications (including liquid form for suspected noncompliance); episodes of inappropriate behavior requiring intervention; noncompliance with treatment regimen; suicidal ideation/threat/gesture/attempt; or lack of availability of appropriate placement options. The plan of care must be reviewed at least every 30 days and continued stay updates (Master Treatment Plan, utilization review worksheet, progress notes) must be maintained for review.at least one

See Rules 560-X-41-.09(4), 560-X-41-.11, and 560-X-41-.14

PRTF Certification of Need

Certification for PRTF admissions

PRTF certification requirements for elective admissions: For elective/non-emergency PRTF admissions of Medicaid-eligible individuals, an independent team that includes a physician and members competent in diagnosis and treatment must certify that community ambulatory resources do not meet the recipient's needs, inpatient services under physician direction are required, and services can reasonably be expected to improve or prevent regression. The independent team shall complete and sign Certification of Need for Services: Non-Emergency Admission form (#370) not more than 30 days prior to admission.all

See Rule 560-X-41-.13(1)-(5)

PRTF certification requirements for emergency admissions: For emergency admissions or individuals who become eligible for Medicaid after admission, an interdisciplinary team (including specified clinician combinations) must perform certification and complete Certification of Need for Services: Emergency Admission form (#371) within 14 days; for individuals who become Medicaid-eligible after admission the form must be completed on or before the date of Medicaid application and include all days for which payment will be requested.all

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

Required Diagnosis Codes in Medical EvaluationICD-10

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

Applicable diagnosis codes by dateICD-10

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

Therapeutic visit limits for inpatient psychiatric hospital — No more than two visits per 60 calendar days, each visit not exceeding three days

LimitNo more than two therapeutic visits per 60 calendar days per admission, each visit not exceeding three days in duration

Counting period60 calendar days (the first calendar day begins with the day of admission)

Billing restrictionTherapeutic visits exceeding three days are not covered and may not be billed to Medicaid

Retrospective reviewTherapeutic visit records will be reviewed retrospectively by the PA Unit; payments in excess will be recouped

Provider Responsibilities, Documentation & Timing

Prior Authorization

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.

Prior Authorization

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.

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

Inpatient — Definition and day-counting rules

DefinitionAn inpatient is a person admitted to a psychiatric facility for bed occupancy to receive inpatient psychiatric services

Day counting methodDays are full calendar days counted midnight-to-midnight (a day begins at midnight and ends 24 hours later)

Payment for admission/dischargeMedicaid covers the day of admission but not the day of discharge

Active treatment — Plan of care timing and review requirements

Plan development timeframeIndividual plan of care must be developed and implemented no later than 14 days after admission

Plan purposeDesigned to achieve the recipient's discharge at the earliest possible time

Level-of-Care: Inpatient vs PRTF Criteria

Active Treatment & Care Planning

Individualized active treatment plan

Plan content: Plan must prescribe an integrated program of therapies, activities, and experiences designed to meet treatment objectives and include post-discharge coordination with family, school, and community.

See Rule 560-X-41-.06

General active psychiatric treatment

Active treatment requirement: Active treatment is implementation of a professionally developed and supervised individualized plan of care with at least one professional team member providing active intervention for an unresolved or active problem as noted on the plan of care.all

See Rule 560-X-41-.09(3)

Therapeutic Visit Limits

Therapeutic visits away from inpatient psychiatric hospital (each visit <= 3 days) — Allowed visits and limits

Authorized visitsTherapeutic visits away from the psychiatric hospital to home, relatives, or friends are authorized if certified by the attending physician as medically necessary

Per-admission limitMaximum of 2 visits per 60 calendar days per admission

Maximum duration per visitEach visit may not exceed three days in duration

Policy Revision History

2021-03-15Amendment EffectiveLatest

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.

2020-06-14Amendment Effective

Amendments to PRTF enrollment/certification rules were filed April 20, 2020 and became effective June 14, 2020.

2020-02-14

Policy Summary

PayerAlabama Medicaid

PolicyGeneral — Psychiatric Facilities for Individuals Under Age 21

Policy CodePolicy 560-X-41-.01

Change TypeNo material change

Effective DateMar 15, 2021

Last ReviewMar 15, 2021

Next Review Date

Key ActionComplete Certification of Need (PSY-2 or form #370/#371 as applicable) prior to non-emergency admission or within required timeframe to preserve payment.

SourceLink

On This Page

Independent team must include a physician and have competence in diagnosis/treatment (preferably child psychiatry) and knowledge of the individual.

Step Therapy

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

Step therapy: not specified

No step therapy protocol is specified in this section.

Documentation Required

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.

Documentation Required

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.

Documentation Required

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.

Documentation Required

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.

Denial Risk

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.

Prior Authorization

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).

Billing Rule

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.

Documentation Required

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.

Review frequencyBe reviewed at least every 30 days by the interdisciplinary team

Plan contentBased on diagnostic evaluation; states treatment objectives; prescribes integrated therapies; includes post-discharge coordination

Active treatment — Definition and team involvement

DefinitionActive treatment = implementation of a professionally developed and supervised individualized plan of care

Team involvementAt least one professional member of the interdisciplinary treatment team must provide active intervention for an unresolved or active problem noted on the plan of care

DocumentationAppropriate team members must document active intervention when placement options are unresolved

Amendments filed December 12, 2019 became effective February 14, 2020 (Rule No. 560-X-41-.01 history shows this amendment).

2015-10-01Amendment Effective

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.

2001-12-14New Rule / Amendment Effective

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.