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Behavioral Health Medical Necessity Criteria — Inpatient, Diversionary, Residential, and Community Behavioral Health Services

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Defines Carelon Behavioral Health's Medical Necessity Criteria (MNC) for inpatient and diversionary behavioral health services in Massachusetts, describing admission, continued stay, discharge, and exclusion criteria for multiple levels of care and guidance for determining applicable criteria.

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CurrentBeacon-Health-OptionsPolicy N/A

Behavioral Health Medical Necessity Criteria — Inpatient, Diversionary, Residential, and Community Behavioral Health Services

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Policy Summary

PayerBeacon-Health-Options

PolicyBehavioral Health Medical Necessity Criteria — Inpatient, Diversionary, Residential, and Community Behavioral Health Services

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Last ReviewJan 1, 2026

Next Review DateN/A

Key ActionSubmit required prior-authorization documentation including a comprehensive behavioral health assessment and individualized treatment plan to verify medical necessity.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

annualMNC reviewed/updated frequency

2Medicare NCD/LCD cited

30 daysTCU transition timeframe

5 hrs/wkCo-Occurring RRS minimum hours

45 daysABA assessment window

Coverage & Medical Necessity Criteria

inv-01: Acute High-Intensity Inpatient — Admission — ALL required

Acute, High-Intensity Inpatient Services provide enhanced-security, higher-staffing psychiatric inpatient care for members whose risk or behavior cannot be safely managed on a general psychiatric inpatient unit. Covered when ALL of the following are met:

ALL of the following

Member meets general Inpatient Psychiatric Services admission criteria.
The member presents a current threat of harm to self or others that is not likely to be safely managed on a general inpatient psychiatric unit, evidenced by the need for observation and intervention beyond the usual capacity of a general unit (e.g., sustained need for >1:1 staff observation).
The member's treatment requires staff with specific training and skills to treat and contain atypical aggressive, assaultive, or dangerous behavior beyond the abilities of typical general inpatient psychiatric unit staff.
The member's treatment and maintenance of safety require a highly structured clinical program and environment (for example: single rooms, limited census, enhanced staffing, and increased observation).
AND at least one of the following must be met as evidence of danger to self or others:
- Established history of significant treatment‑resistant assaultive behavior to self and/or others.
- Recent history of behaviors that were not successfully or safely managed on a general inpatient psychiatric unit.
- The member is actively engaged in significant dangerous behavior not responsive to usual interventions at less‑intensive levels of care.
- Significant history of dangerous sexualized behavior (e.g., registered Level III sex offender) requiring specialized containment.

inv-02: Acute High-Intensity — Continued Stay — ALL required

Continued stay for Acute High‑Intensity Inpatient is authorized when ALL of the following are met:

ALL of the following

Member continues to meet admission criteria for Acute, High‑Intensity Inpatient Mental Health Services and requires the specialized milieu, increased observation, and enhanced staffing levels described for this level of care.
Treatment interventions have not yet been exhausted and no other less‑intensive level of care would be adequate to safely manage the member's needs.
The member continues to require staffing and clinical resources beyond those available on a general inpatient unit (e.g., specialized staff trained to contain atypical aggressive/assaultive behavior).

inv-03: Acute High-Intensity — Discharge — ANY of the following

Discharge from Acute High‑Intensity Inpatient is appropriate if ANY of the following apply:

ANY of the following

The member no longer meets admission/continued stay criteria for Acute High‑Intensity Inpatient and can be safely treated in a general inpatient psychiatric unit or another less‑intensive level of care.
Treatment plan goals and objectives have been substantially met and a safe continuing care program at a less‑intensive level is arranged and deployable.
The member is not making progress toward treatment goals and there is no reasonable expectation of progress at this level of care (including when high‑intensity need reflects a chronic condition better served by transfer to a long‑term care setting).

inv-04: Acute High-Intensity — Exclusions — any one sufficient

Exclusion — any one of the following is sufficient to exclude Acute High‑Intensity Inpatient admission:

ANY of the following

The member can be safely maintained and effectively treated at a less‑intensive level of care.
The primary problem is not psychiatric (for example, social, legal, or purely medical problems) without a concurrent major psychiatric episode meeting criteria for this level of care; admission for respite, housing, or as an alternative to incarceration is not appropriate.
Medical condition requires treatment in a medical/surgical setting, or medical co‑morbidities cannot be safely managed in this specialty psychiatric setting.
Behavioral dyscontrol is primarily attributable to conditions such as traumatic brain injury, intellectual disability, pervasive developmental disorder, dementia, or other medical conditions without evidence of an acute DSM‑5‑TR psychiatric diagnosis requiring this level of care.

Coverage & Medical Necessity Criteria

Community‑Based Acute Treatment (CBAT) provides 24/7 staff‑secure acute services for children/adolescents who require a highly structured therapeutic environment. Admission, continued stay, discharge, and exclusion rules are summarized below.

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Level-Specific Admission, Continued Stay, and Discharge Rules

Services & Modalities

Prior Authorization, Documentation & Operational Requirements

Prior Authorization

Prior Authorization — Co-Occurring Enhanced RRS

Co-Occurring Enhanced RRS: Prior authorization required. Admission must be supported by an ASAM-based assessment (six ASAM dimensions) and documentation of co-occurring DSM-5-TR/ICD diagnoses. Prior utilization history (recent inpatient psych hospitalization, ≥2 ED/MCI evaluations, or unsuccessful engagement in community services within past 3 months) must be documented. Members discharged from inpatient psych or post-withdrawal induction on MAT may be admitted when stabilized and documentation and coordination with inpatient providers is provided. Exclusion triggers: medically monitored withdrawal or hospital-level needs, inability to be safely treated in community, lack of a co-occurring MH diagnosis, or ability to be treated in a Co-Occurring Capable RRS. Step-up rule: member should step up from Co-Occurring Capable RRS only after less-intensive RRS has been tried and found insufficient; document prior attempts and rationale.

Required: ASAM six-dimension assessment; DSM-5-TR/ICD diagnoses; recent service utilization history (see above).
Prior authorization applies to admissions and continued stay determinations.

Documentation Required

Coding, External References & Key Numeric Limits

Medicare coverage referencesmixed

CMS LCD L33624	Inpatient Psychiatric Hospitalization (Medicare reference)
CMS NCD 130.1	Inpatient Hospital Stay for Alcohol Detoxification (Medicare reference)

Referenced Medicare NCD/LCDmixed

NCD 130.2	Outpatient Hospital Services for Treatment of Alcoholism (Medicare only)
NCD 130.5	Alcohol and Drug Abuse Treatment Services in a Freestanding Clinic (Medicare only)
NCD 130.6	Outpatient Treatment of Drug Abuse (Chemical Dependency) (Medicare only)
NCD 130.7	Outpatient Hospital Withdrawal Treatments for Narcotic Addictions (Medicare only)
LCD L33632	Psychiatry and Psychology Services (Medicare only)

Minimum weekly clinical service hours for Co-Occurring Enhanced RRS

Minimum weekly clinical service hours>= 5 hours per week of scheduled clinical services

Service contextApplies to Co-Occurring Enhanced Residential Rehabilitation Services (RRS, ASAM Level 3.1)

Concurrent careAdditional outpatient levels of care may be accessed concurrently as appropriate

Expected TCU transition timeframe

Expected transition timeframe30 days or less (services designed to facilitate transition in ≤ 30 days)

Target populationYouth whose placement is the responsibility of a state-supported agency or designated by the state

Applied Behavior Analysis — Authorization & Treatment Criteria

Note

Service Durations, Frequency & Limits

Co-Occurring Enhanced RRS clinical services — minimum 5 hours/week required

Minimum weekly clinical service hours>= 5 hours per week of scheduled clinical services (minimum) for Co-Occurring Enhanced RRS

ASAM alignmentService meets ASAM Level 3.1 definition for Co-Occurring Enhanced RRS

Concurrent servicesAdditional outpatient levels of care may be accessed concurrently as appropriate

FIT / AMCI — FIT flexible; AMCI stabilization up to 3 days

FIT session timing and durationFIT sessions are flexible and not time-limited; frequency and duration match need with 24/7 urgent response capability

AMCI stabilization durationAMCI provides stabilization and follow-up for up to three days

Key Terms & Definitions

Acute, High-Intensity Inpatient Services — definition and characteristics

DefinitionA specialized inpatient psychiatric service with enhanced security, single rooms, limited census, enhanced staffing, and increased observation to manage atypical aggressive or dangerous behavior

Primary goalAcute stabilization and treatment to enable transition to general inpatient unit or less-intensive care

Key components24-hour skilled nursing, daily medical care, multidisciplinary assessments, multimodal interventions, and specialized milieu

CBAT (Community-Based Acute Treatment) — definition

DefinitionCommunity-Based Acute Treatment (CBAT) is a 24/7 staff-secure (unlocked) acute treatment setting for children/adolescents requiring intensive therapeutic intervention and multidisciplinary treatment planning

Core services

Background & Scope

This document defines Carelon Behavioral Health's structured Medical Necessity Criteria for the behavioral health continuum in Massachusetts. It provides explicit admission, continued stay, discharge, and exclusion rules across inpatient high‑intensity care, 24‑hour diversionary services (e.g., CBAT, ICBAT, DDAT), in‑home and community services (IHT, IHBS, TM, FIT), mobile crisis (AMCI/YMCI), outpatient modalities (DBT, ABA, EIBI), and Community Support Programs (CSP‑JI, CSP‑HI, CSP‑TPP). The criteria reference external standards (e.g., ASAM, Medicare NCD/LCD) where applicable and supply operational thresholds such as expected TCU transition timeframe ≤ 30 days and CSP‑HI pre‑housing billing windows up to 120 days before move‑in.

Policy Summary

PayerBeacon-Health-Options

PolicyBehavioral Health Medical Necessity Criteria — Inpatient, Diversionary, Residential, and Community Behavioral Health Services

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Last ReviewJan 1, 2026

Next Review DateN/A

Key ActionSubmit required prior-authorization documentation including a comprehensive behavioral health assessment and individualized treatment plan to verify medical necessity.

SourceLink

On This Page

Current legal charges (e.g., murder, aggravated assault, rape) for which the member is more appropriately served in a specialized forensic program.

IHT Service Delivery & Team Requirements

In-Home Therapy (IHT) delivery requires a multidisciplinary team (licensed clinician plus paraprofessionals as needed), 24/7 urgent response capability, flexible, needs‑matched session duration, and services delivered in natural environments (home, school, community). Treatment planning is team-based with family involvement; identification of natural supports and care coordination is required. Exclusion triggers include residence in a hospital or residential setting not ready for family/home discharge, concurrent FIT enrollment, services fully meeting needs, unsafe environment for provider, independent living not returning to family, or medical conditions preventing benefit.

Team composition: qualified practitioner(s) and paraprofessional(s); licensed clinician develops and supervises treatment plan.
Operational expectations: 24/7 urgent response, flexible session lengths, sessions where youth naturally located.
Document: treatment plan, consent, MA CANS where indicated, active coordination with PCP and other providers.

Documentation Required

Assessment & Treatment Plan Required for Admission

A comprehensive assessment and an individualized treatment plan are required at admission for applicable levels of care. Assessments must include DSM-5-TR/ICD diagnoses, relevant standardized tools (MA CANS when applicable), ASAM dimensions for SUD levels, functional/behavioral assessments (FBA/FA) when addressing behaviors, observations, and utilization history. Treatment plans must be multidisciplinary, measurable, time-framed, list services/roles, safety/risk management, discharge planning, and family/caregiver involvement.

Assessment elements: DSM-5-TR/ICD diagnosis, MA CANS (where required), ASAM dimensions for SUD, prior treatment/utilization history, FBA when indicated.
Treatment plan elements: measurable goals/objectives, frequency/intensity rationale, coordination plan, discharge planning, consent documentation.

Prior Authorization

Emergency Services — No Prior Authorization; Evaluation & Notification

Emergency services (AMCI/YMCI and ED evaluations) do not require prior authorization. Providers must perform face-to-face evaluations when acute services are needed and notify the plan with relevant clinical information as soon as possible and no later than 24 hours after emergency admission. Consent refusal for mobile crisis evaluation excludes the service and may result in denial.

AMCI: 24/7, up to 3 days for adults; YMCI: 24/7, up to 7 days for youth <21.
When AMCI/YMCI unavailable within one hour at site, hospital behavioral health clinician may perform evaluation.
Providers must attempt timely notification to the plan (clinical info within 24 hours).

Note

YMCI — Service Availability & Scope

YMCI availability and scope: YMCI operates 24/7/365, provides mobile/community and telehealth responses when clinically appropriate, and offers up to seven days of crisis intervention for youth under 21, including on-site face-to-face response, psychiatric consultation, urgent psychopharmacology, development of safety plans, and linkage to continuum services. Admission requires prior phone triage attempts and evidence that less-intensive triage/stabilization were insufficient.

YMCI must accept voluntary ambulance or law‑enforcement drop‑offs and coordinate with YCCS/CBHC.
Admission prerequisites: failed phone triage, immediate need for intervention, and presence of risk/impairment per admission criteria.

Prior Authorization

Prior Authorization — ABA Initial Assessment & Treatment

Applied Behavior Analysis (ABA) initial assessment and treatment require prior authorization. Initial assessment authorization prerequisites include confirmed ASD/Down Syndrome diagnosis, multidisciplinary diagnostic evidence, medical screening, and submission of an initial treatment plan within 45 days. Initial treatment authorization requires comprehensive history, functional assessments, FBA/BIP when treating behaviors, measurable ABA goals, parent/caregiver involvement plan, treatment intensity justification, and documentation that no more conservative/less costly medically appropriate services are available.

Within 45 calendar days of assessment auth, up to 12 hours of assessment completed to inform initial plan.
Initial treatment plan must include goals, service component breakdown (LABA vs technician hours), cultural/linguistic considerations, and titration/step‑down plan.
Conservative-alternative requirement: document that less‑intensive services (school IEP, early intervention, S/L/OT, CBHI) are not suitable or available.

Prior Authorization

Prior Authorization — EIBI Assessment

Early Intensive Behavioral Intervention (EIBI) assessments for children under three may require prior authorization for assessment. Providers should seek authorization as indicated to allow prompt initiation of services once diagnosis is confirmed; EIBI admission requires referral from Early Intervention and confirmed ASD diagnosis. If an authorization is required, it may be obtained before family selects a specific provider in most cases.

Admission prerequisites: referral from EIP and confirmed ASD diagnosis (DSM-5-TR referenced).
If prior auth required, it can often be obtained prior to specific provider selection.

Billing Rule

CSP Admission Verification & CSP-HI Billing

CSP admission verification (effective Jan 1, 2025+): for CSP-JI/CSP-HI admissions, clinical criteria may be verified by diagnosis or member attestation. For members enrolled in an Accountable Care Partnership Plan or Primary Care ACO, medical necessity may be demonstrated either by meeting CSP clinical criteria or via an approved Health Needs Based Criterion as verified by diagnosis or member attestation. CSP-HI billing may begin up to 120 days before move‑in and may continue after move-in until plan determines services are no longer medically necessary. CSP-HI cannot fund housing goods (e.g., deposits, furnishings).

For CSP-HI: member must meet chronic homelessness or high acute service use thresholds and have identified PSH with move-in within 120 days.
Billing window: providers may bill CSP-HI as early as 120 days pre-move; continue billing post‑move until plan ends medical necessity.

Denial Risk

Escalation Requirement & Exclusion Triggers — High-Intensity Inpatient

High-Intensity (Acute) Exclusion & Escalation Requirements: Members who can be safely treated at a less-intensive level are excluded from Acute High-Intensity inpatient services. For escalation to High-Intensity care, general inpatient criteria must be met and less‑intensive interventions must have been considered and tried when clinically appropriate; document attempts and rationale for escalation. Exclusion triggers include primary non-psychiatric problems, medical conditions requiring medical/surgical setting, medical comorbidities not manageable in specialty setting, cognitive/ developmental conditions without acute DSM-5-TR diagnosis, and certain legal statuses requiring forensic programs.

Escalation requires documentation that less-intensive services were insufficient and that the member meets High-Intensity admission criteria (e.g., need for specialized milieu, enhanced staffing).
Exclusion: safe management in less-intensive setting is sufficient to deny High-Intensity admission.

Denial Risk

Exclusion Conditions that Trigger Non-Authorization

Common exclusions across diversionary and community services: receiving similar services already, lack of voluntary consent, being in an inappropriate setting (hospital, PRTF, SNF, residential) and not ready for discharge, imminent risk requiring higher level of care, medical or developmental conditions precluding benefit, or guardianship/consent issues. Specific programs (TCU, FS&T, ICC/IHT/IHBS, IHBS, FIT, CPS, DBT, C-L psychiatry, CSP-JI) have tailored exclusion criteria consistent with these general principles.

TCU exclusions: youth at imminent risk to self/others, lack of guardian consent, complex medical/developmental conditions, or need for more-intensive long-term placement.
FS&T exclusions: no expectation of progress, environment unsafe, or needs already met by other services.
IHBS/IHT/ICC exclusions: residential/hospitalized status, not ready for community return, unsafe environment, or duplicative services.
FIT exclusions: consent missing, concurrent services that preclude FIT, age limits, or not evaluated by YMCI/ED when required.

Documentation Required

CBAT — Documentation Expectations

CBAT documentation expectations: multidisciplinary individualized treatment plan, frequent review and updates, family/caregiver involvement (including family therapy), daily medication monitoring when indicated, nursing and psychiatric availability, discharge planning beginning at admission with active efforts documented to reintegrate to home/school/community or identify alternative placement.

Document active family involvement, medication reconciliation/monitoring, psychological testing if needed, and discharge planning from day one.

Documentation Required

Assessment & Utilization History Documentation

Assessment and utilization history documentation requirements: ASAM dimension assessment for SUD levels, DSM-5-TR/ICD diagnoses, prior treatment history (inpatient stays, ED/MCI encounters, engagement attempts), and evidence of prior less-intensive interventions when required for step-up decisions.

Include timeline of prior services/utilization and objective evidence supporting need for current level of care.

Documentation Required

Required Documentation for Initial & Continuing Authorization

Required documentation for initial and continuing authorization (across applicable services): current treatment plan with measurable goals and objectives, summary of services requested and intensity rationale, data demonstrating progress (e.g., behavior graphs, session notes), updated assessments at required intervals (e.g., every six months for ABA), coordination attempts with other providers and agencies, consent, and safety/risk management plans.

For ABA: 6-month plan updates, data showing change from baseline, daily session notes, parent involvement evidence, and utilization at ≥75% of approved hours unless mitigated.
For all services: documentation of coordination attempts and discharge planning starting at admission.

Documentation Required

AMCI Documentation Requirements

AMCI documentation (Adult Mobile Crisis Intervention): crisis assessment, collateral contacts, coordination with other providers, short-term crisis counseling notes, medication evaluation and prescriptions as applicable, and linkage/referral documentation.

Document crisis assessment findings, risk/safety plan, and follow-up arrangements.

Documentation Required

Care Coordination & Discharge Planning Documentation

Care coordination and discharge planning: active discharge planning must begin at admission for 24-hour and diversionary services. Documentation must show coordination with PCPs, specialty providers, state agencies, schools, and prior treatment teams; include attempts when collaboration is unsuccessful; and show linkages to outpatient follow-up and natural supports.

Record attempts to coordinate care and reasons when coordination cannot be completed.
Discharge planning should include reintegration plans to home/school/community or identification of alternative placements.

Documentation Required

Required Documentation — CPS / ABA

Required documentation for CPS and ABA services: CPS must document face-to-face, telephonic, and collateral contacts, active wellness/treatment planning, coordination with other providers, and ongoing discharge planning. ABA documentation must include comprehensive assessment data, FBA/BIP when treating problem behaviors, measurable goals, parent training records, session notes, graphs of progress, and evidence supporting intensity and conservative-alternative considerations.

CPS: document wellness plan activities, coordination, and when medically necessary facilitate psychopharmacologic access.
ABA: include two direct observations, standardized assessments, FBA/BIP, treatment intensity justification, titration/step‑down plan, and conservative alternatives search.

Documentation Required

Psychiatric Consultation Documentation & Exclusion Risk

Psychiatric consultation (C-L psychiatry) documentation: clinical history, mental status exam, safety/stability assessment, medication recommendations when appropriate, and an active treatment plan. Exclusion: consultation not clinically indicated (i.e., member can be safely maintained without psychiatric consultation).

Document sources of collateral information, rationale for consultation, and recommended follow-up.

Documentation Required

CSP-JI / CSP-HI Admission Documentation

CSP-JI / CSP-HI admission documentation: verify justice involvement when applicable, document barriers to community tenure and that member meets general CSP clinical criteria (diagnosis or attestation). For dates of service on/after Jan 1, 2025, ACO/ACP plan enrollees may alternatively verify with Health Needs Based Criteria. Document housing status, imminence of housing (PSH move-in within 120 days) for CSP-HI, and acute service utilization thresholds when applicable.

CSP-HI: document chronic homelessness or frequent acute service use thresholds and PSH identified with planned move-in within 120 days; document consent.
For CSP-TPP: document eviction risk and court status per eligibility rules.

Step Therapy

Step Therapy Rules, Intensity & Step-Down Planning

Step therapy rules: not applicable to the majority of behavioral health levels of care in this chapter. Instead, clinical authorization focuses on medical necessity, exclusions, concurrent services, consent, and court status rather than formal step‑therapy sequences. However, many community services require attempts of less‑intensive interventions before stepping up (document prior less-intensive attempts and ongoing eligibility).

Providers must document prior attempts at less‑intensive services when the policy requires step‑up justification (e.g., IHBS, Co-Occurring Enhanced RRS, FIT eligibility).
Intensity and step-down planning: requests must reflect the least intensive level capable of achieving goals and include a titration plan for step‑down.

Step Therapy

Step-Up Requirements & Triage Before YMCI

Program-specific step-up requirements: IHBS and other intensive home/community services require evidence that less‑intensive interventions were tried and failed. FIT is indicated only when outpatient, IHT, or ICC are insufficient; triage/phone diversion attempts are required before YMCI engagement. Document prior service attempts and rationale for escalation.

Record phone triage attempts and diversion efforts prior to YMCI referral.
For IHBS: document unsuccessful trials of less‑intensive behavioral interventions.

Documentation Required

ABA — Intensity, Conservative-Alternative & Titration Planning

ABA intensity, conservative-alternative, and titration requirements: requested intensity must be individualized, data-driven, and reflect the least-intensive level capable of achieving goals. Include a titration/step‑down plan and criteria to adjust intensity. Demonstrate consideration of conservative/less-costly alternatives and why they are unsuitable.

Titration plan: specify how and when hours will be decreased and how generalization will be supported.
Conservative alternatives: document search and rationale (IEP, early intervention, S/L/OT, CBHI, reduced ABA hours).

PurposeSupports community exposure/therapeutic milieu to enable discharge to home/foster/group/ residential setting

ABA assessment completion window (45 days; up to 12 hours direct/indirect)

Assessment completion windowWithin 45 calendar days of initial assessment authorization

Assessment hoursUp to 12 hours of direct and indirect assessment to inform initial treatment plan

Submission requirementInitial treatment plan must be submitted for review and authorization of initial treatment

Intensive treatment threshold — 20+ hours/week

Intensive treatment thresholdIntensive ABA typically defined as 20+ hours per week of direct/group/family services

Guidance natureTreatment Intensity Guidance Grid provides general guidance, not fixed requirements

IndividualizationIntensity must be individualized based on functional/behavioral needs and supports

Utilization adherence threshold — <75% utilization may trigger review

Utilization adherence thresholdUtilization below 75% of approved direct service hours across a complete review cycle may trigger additional review or discharge

Documentation when low utilizationProviders must document barriers and mitigation activities when utilization is <75%

Impact on continuing authorizationLow utilization may prompt review of continuing medical necessity and service adjustments

Frequent acute health service use (ED) thresholds

Frequent ED use thresholdFour or more ED visits within the past 12 months (HNBC also defines repeated ED use as ≥2 visits within 6 months)

Alternative HNBC thresholdRepeated ED use per HNBC: ≥2 visits within 6 months

Context of useUsed to establish frequent acute health service use for CSP-HI eligibility and HNBC determinations

Frequent inpatient use threshold

Frequent inpatient use thresholdThree or more acute and/or psychiatric hospital inpatient admissions within the past 12 months

Use in eligibilityApplies to determination of frequent acute health service use for homelessness-related CSP eligibility

Measurement periodLook-back period: 12 months from date of evaluation

Pre-housing billing window for CSP-HI

Pre-housing billing windowProviders may begin billing for CSP-HI up to 120 days before a member moves into housing

Post-move billingBilling may continue after the member obtains housing until the plan determines CSP-HI is no longer medically necessary

Imminent housing definitionMember must have identified a PSH opportunity and will move into housing within 120 days

Team composition (FIT)FIT delivered by a team including clinician, paraprofessional, and Family Partner with robust care coordination

ABA initial assessment (direct and indirect) — up to 12 hours

ABA initial assessment maximum hoursUp to 12 hours of direct and indirect assessment may be completed to inform the initial treatment plan

Assessment completion timeframeAssessment must be completed within 45 calendar days of initial assessment authorization

Authorization stepInitial treatment plan must be submitted for plan review and authorization of initial treatment

Daily medication monitoring, psychiatric assessment, nursing availability, individual/group/family therapy, case management, family assessment/consultation, discharge planning

Family involvementActive family/caregiver involvement through family therapy is expected and discharge planning begins at admission

Co-Occurring Enhanced RRS — definition (RRS Level 3.1)

DefinitionCo-Occurring Enhanced Residential Rehabilitation Services (RRS) are ASAM Level 3.1 24-hour community-based programs for members with SUD and moderate-to-severe mental health issues

EnvironmentSafe, structured community milieu that supports recovery and reintegration with scheduled goal-oriented clinical services and psychiatry/medication management

Minimum clinical services>= 5 hours per week of scheduled clinical services

Transitional Care Unit (TCU) — definition and expected ≤30 days

DefinitionTransitional Care Unit (TCU) is a short-term placement for youth who no longer meet inpatient/ICBAT criteria but need transitional supports to secure placement

Intended populationYouth under state agency responsibility (e.g., DCF, DMH, DYS) or as designated; expected placement is home/foster/group home/residential program

Length of stay expectationServices designed to facilitate transition in 30 days or less

DDAT — definition

DefinitionDual Diagnosis Acute Treatment (DDAT) provides 24-hour medically monitored evaluation, care, and treatment for co-occurring substance use and mental health disorders with physician/psychiatrist availability

Setting and staffingTypically delivered in licensed acute care or detoxification settings with 24-hour nursing and physician/psychiatrist consultation availability

ServicesIncludes medically monitored detox as needed, counseling staff trained in addiction and mental health, and family involvement when appropriate

Intensive Care Coordination (ICC) — wraparound-based care planning definition

DefinitionIntensive Care Coordination (ICC) is a wraparound-based care planning service providing a single point of accountability via a care coordinator who convenes a Care Planning Team and develops an Individual Care Plan (ICP)

Key functionsCare coordinator organizes and matches care across providers/child-serving systems, convenes CPT meetings, implements ICP, monitors progress, and coordinates services

PopulationTargeted to youth with Serious Emotional Disturbance (SED) under age 21 (MassHealth) or specified commercial criteria

In-Home Therapy (IHT) — team-delivered therapy definition

DefinitionIn-Home Therapy (IHT) is team-delivered therapy in home/community by licensed clinicians and paraprofessionals offering therapeutic interventions and Therapeutic Training and Support

Service featuresIncludes 24/7 urgent response capability, flexible scheduling, sessions matched to need, and coordination of care with identification of natural supports

Delivery settingsProvided in home, school, childcare centers, respite settings, and other natural community locations

In-Home Behavioral Services (IHBS) — behavior management definition

DefinitionIn-Home Behavioral Services (IHBS) deliver Behavior Management Therapy and Behavior Management Monitoring in-home to assess, develop, and implement specific behavior plans

Therapy vs monitoringBehavior Management Therapy: assessment, FBA, development and supervision of behavior plan; Monitoring: implementation, reinforcement, reporting, and caregiver coaching

Integration with other servicesBehavior plans aligned with ICC, FIT, or IHT ICPs when applicable and CPT involvement supports adherence

Family Support and Training (FS&T) — definition and scope

DefinitionFamily Support and Training (FS&T) is a structured one-to-one support for parents/guardians delivered by paraprofessionals under licensed clinician supervision to improve caregiver capacity

PurposeImprove caregiver capacity to address youth emotional/behavioral needs and support reintegration into home/community

Delivered byQualified paraprofessionals supervised by a licensed clinician, working with outpatient/IHT treatment plans or ICPs

Behavior Management Therapy — definition

DefinitionBehavior Management Therapy: assessment, development of a specific behavior plan, supervision/coordination of interventions, and training of other interveners to address behavioral objectives

IncludesFunctional Behavioral Assessment (FBA), Behavior Intervention Plan (BIP), direct observations, and coordination with caregivers/providers

GoalDiminish, extinguish, or improve target behaviors to restore functioning across settings

Behavior Management Monitoring — definition

DefinitionBehavior Management Monitoring: implementation and monitoring of the behavior plan, reinforcing caregiver implementation, and reporting progress; may include phone contact/consultation

RoleSupports ongoing fidelity of plan implementation and documents progress toward behavioral objectives

InteractionWorks in tandem with Behavior Management Therapy and caregiver training to sustain gains

SED — Serious Emotional Disturbance definition

DefinitionSerious Emotional Disturbance (SED) describes diagnosable mental/behavioral disorders with functional impairment substantially interfering with youth's role/functioning

ComponentsIncludes duration and degree of impairment criteria per Part I and Part II definitions (DSM/ICD alignment and educational impact), excluding certain primary conditions unless co-occurring

UseSED determination used for FIT, ICC, and other youth-targeted services eligibility

FIT — Family-based Intensive Treatment definition and team composition

DefinitionFamily-based Intensive Treatment (FIT) is a team-based in-home/community service including clinician, paraprofessional, and Family Partner providing intensive family therapy and care coordination

Key features24/7 urgent response, flexible session frequency/duration matched to need, goal of transitioning youth to less-intensive services within 4–6 months

Primary modalityIn-person in natural settings (home, school, community) with strong caregiver engagement

YMCI — Youth Mobile Crisis Intervention definition

DefinitionYouth Mobile Crisis Intervention (YMCI) provides community-based crisis assessment, intervention, stabilization and follow-up for youth under 21, available 24/7/365

DurationUp to seven days of crisis intervention and stabilization services

ComponentsOn-site face-to-face therapeutic response, psychiatric consultation, urgent psychopharmacology as needed, referrals and linkages

Community Crisis Stabilization (ACCS/YCCS) — definition

DefinitionCommunity Crisis Stabilization (ACCS/YCCS) is a facility- or community-based program providing continuous 24-hour observation and supervision as an alternative to hospitalization for short-term stabilization

ServicesCrisis stabilization, bio-psychosocial assessment, care management, medication management, mobilization of family/supports, and linkage to community resources

ObjectiveRapid comprehensive assessment and development of plan to stabilize and restore functioning to a less-restrictive level of care

Diagnostic Evaluation — definition

DefinitionDiagnostic Evaluation: assessment of level of functioning including physical, psychological, social, educational, and environmental strengths and challenges for diagnosis and treatment planning

PurposeUsed to inform treatment planning, ICPs, and level-of-care determinations

ComponentsMay include medical screening, developmental history, formal assessments and observations

Inpatient-Outpatient Bridge Visit — definition

DefinitionInpatient-Outpatient Bridge Visit: single-session consultation by an outpatient BH provider while member remains inpatient, involving meeting with member and inpatient team

PurposeFacilitate safe transition and continuity of care between inpatient and outpatient teams

Typical activityOutpatient provider meets inpatient team to review treatment plan and coordinate discharge steps

DBT — definition and scope

DefinitionDialectical Behavioral Therapy (DBT) is a manual-directed outpatient treatment combining behavioral, cognitive, and supportive psychotherapies for borderline personality disorder and related conditions

Core componentsInitial readiness evaluation, weekly 2-hour skills group, minimum 1-hour individual therapy every other week, 24-hour telephone coaching, team consultation; typical 6–12 month agreement

Target populationMembers with borderline personality disorder, chronic parasuicidal behaviors, and select related conditions

ABA — definition

DefinitionApplied Behavior Analysis (ABA) is a scientific discipline focusing on analysis, design, implementation, and evaluation of environmental modifications to produce meaningful behavior change using direct observation and measurement

ComponentsDirect/indirect services, functional analysis, behavior intervention plans, parent training, and generalization across settings

Use caseApplied for ASD and related conditions to improve functional communication, adaptive skills, and reduce challenging behaviors

EIBI — definition and typical age range

DefinitionEarly Intensive Behavioral Intervention (EIBI) is an intensive ABA program typically for children 0–3 years delivered in natural home or community settings (not center-based)

Typical age rangePrimarily for children under age 3 with referral from Early Intervention (EIP)

Delivery settingHome and community (natural settings) with parent/caregiver involvement and BCBA/LABA oversight

Justice Involvement / Justice Involved — definition

DefinitionJustice Involvement / Justice Involved: a member who is a former inmate/detainee released within the past year or under supervision of Massachusetts Probation/Parole

Use in policyUsed to determine eligibility and documentation requirements for CSP-JI and related services

VerificationJustice involvement status should be documented when admitting to justice-involvement–targeted programs

Chronic Homelessness — HUD definition

Chronic Homelessness (HUD)Disabled individual continuously homeless for ≥12 months or with ≥4 episodes over 3 years totaling ≥12 months, with qualifying disability

Homelessness definitionLack of fixed, regular, adequate nighttime residence including places not meant for habitation or emergency shelters

PSH and Housing FirstPermanent Supportive Housing (PSH) pairs subsidized housing with flexible supports; 'Housing First' prioritizes rapid housing entry then supports

Permanent Supportive Housing (PSH) — definition and Housing First approach

DefinitionPermanent Supportive Housing (PSH): subsidized housing combined with flexible health and social supports; 'Housing First' prioritizes rapid housing entry

PurposeSupports long-term housing stability for persons experiencing chronic homelessness by coupling housing with services

Relation to CSP-HIPSH opportunities are a qualifying condition for CSP-HI admission when move-in is within 120 days

Chronic Homelessness / Homelessness — HUD-defined lack of fixed nighttime residence

DefinitionHomelessness: lack of a fixed, regular, adequate nighttime residence including living in places not meant for habitation, shelters, or exiting institutions without stable prior housing

IncludesIndividuals exiting institutions if prior residence was shelter or place not meant for habitation; covers a broad HUD-based definition

Use in eligibilityApplied to CSP-HI admission and HNBC determinations

Health Needs Based Criteria (HNBC) — definition and components

DefinitionHealth Needs Based Criteria (HNBC): clinical criteria including behavioral health need, complex physical need, need for ADL/IADL assistance, repeated ED use, or pregnancy/postpartum risk

Repeated ED use thresholdsDefined as ≥2 ED visits within 6 months or ≥4 ED visits within 12 months as part of HNBC

Use for CSP admissionHNBC may be used to verify medical necessity for certain ACO enrollees starting Jan 1, 2025

At Risk of Homelessness — definition

DefinitionAt Risk of Homelessness: member lacking sufficient resources or support networks to prevent moving to an emergency shelter or place not meant for habitation

UseApplied for CSP-TPP admission when member is facing eviction and at risk of homelessness

ContextAssessment includes evaluation of resources and supports available to the member

Eviction / Notice to Quit — definition

DefinitionEviction / Notice to Quit: the legal process to remove a tenant, including serving a Notice to Quit which formally terminates tenancy

Implication for servicesEviction status is a qualifying condition for CSP-TPP admission except when eviction case already went to trial in certain courts

DocumentationProviders should document eviction notices or court filings when assessing CSP-TPP eligibility