CurrentAnthemPolicy C-19002

Partial Hospitalization Program and Intensive Outpatient Program Services - Facility

Defines Anthem's facility reimbursement rules for Partial Hospitalization Program (PHP) and Intensive Outpatient Program (IOP) services for commercial members, including billing units, bundled services, and reporting expectations; applies to facilities submitting claims to Anthem in applicable jurisdictions.

Policy Summary

PayerAnthem

PolicyPartial Hospitalization Program and Intensive Outpatient Program Services - Facility

Policy CodePolicy C-19002

Change TypeAdded all-inclusive languagerevised IOP definition

Effective Date07/23/2025

Next Review Date

Key ActionEnsure services meet authorization and medical necessity guidelines and submit claims with appropriate revenue and HCPCS codes on a UB-04.

SourceLink

POLICY UPDATE CHANGES

Added all-inclusive and ancillary language from retired policy Expenses Included in Facility Charges (C-17001).

Updated Definitions section for IOP.

1unit allowed per date of service for PHP or IOP

9 hrs/weekminimum IOP therapeutic services per week

20 hrs/weekminimum PHP therapeutic services per week

07/23/2025last approval / effective date

Facility PHP and IOP Reimbursement Criteria

PHP/IOP Facility Coverage Criteria

Reimbursement rules for facility Partial Hospitalization Program (PHP) and Intensive Outpatient Program (IOP) services.

Allow reimbursement for one (1) unit per date of service for either Partial Hospitalization Program (PHP) or Intensive Outpatient Program (IOP) services; all other units billed will be denied unless provider, state, or federal contracts and/or requirements indicate otherwise.

Facilities should report the appropriate PHP or IOP specific revenue code and HCPCS code for reimbursement on a UB-04.

Reimbursement is all-inclusive and covers room and board (including all services rendered by facility employees), laboratory, equipment, pharmaceuticals, and other services incidental to the inpatient or outpatient stay; separate reimbursement is not allowed for ancillary services including laboratory, pathology testing, specimen collection, and related supplies provided by an external laboratory.

Allow reimbursement per date of service for either PHP or IOP services, not both.

Policy Summary

PayerAnthem

PolicyPartial Hospitalization Program and Intensive Outpatient Program Services - Facility

Policy CodePolicy C-19002

Change TypeAdded all-inclusive languagerevised IOP definition

Effective Date07/23/2025

Next Review Date

Key ActionEnsure services meet authorization and medical necessity guidelines and submit claims with appropriate revenue and HCPCS codes on a UB-04.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Authorization, Claims Submission, and Provider Responsibilities

Note

Authorization, Medical Necessity, and Claim Submission Requirements

Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis and must be submitted using proper billing formats; facilities must report the appropriate PHP or IOP specific revenue code and HCPCS code on a UB-04. Reimbursement is limited to one (1) unit per date of service for either PHP or IOP — all other units billed will be denied unless overridden by provider, state, or federal contracts or requirements. State and federal law and contract language take precedence when determining coverage eligibility.

Obtain and document any required prior authorization and medical necessity determinations per the member’s contract and state/federal requirements.
Submit facility claims on a UB-04 with the appropriate PHP/IOP revenue code and HCPCS code.
Expect payment for one (1) unit per date of service for either PHP or IOP; additional units will be denied unless contract or regulatory requirements allow.
Verify that state and federal law or contract language do not supersede this policy before billing.

Program Definitions

Intensive Outpatient Program (IOP)

DefinitionStructured, short-term treatment modality that provides a combination of individual, group and family therapy

Intended patient scopePatients with an active psychiatric or substance-related illness who need care more intensive than outpatient day treatment

Minimum therapeutic hoursRequires a minimum of 9 hours of therapeutic services per week

Place in continuumAn alternative to inpatient or partial hospital care; less intense than PHP

Partial Hospitalization Program (PHP)

DefinitionStructured, short-term treatment modality and an alternative to acute inpatient care offering intensive, coordinated multidisciplinary clinical and diagnostic services under the direction of a physician

Intended patient scopePatients requiring a higher level of care than standard outpatient services who need intensive therapeutic services

Minimum therapeutic hoursRequires a minimum of 20 hours of therapeutic services per week

Service componentsIncludes physicians or other qualified health care professionals, nursing services, individual, group, family therapies, and educational services

OpenPayer

Partial Hospitalization Program and Intensive Outpatient Program Services - Facility

Facility PHP and IOP Reimbursement Criteria

Billing, Codes, and Minimum Service Hours

Authorization, Claims Submission, and Provider Responsibilities

Program Definitions