Behavioral Health Residential Facility (BHRF) Admission Criteria
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Defines clinical admission, continued stay, and discharge readiness criteria for members being considered for Behavioral Health Residential Facility care; applies to providers and care teams managing behavioral health residential placement decisions.
No material clinical or coverage changes in this revision.
Behavioral Health Residential Facility Coverage Criteria
inv-01: Admission Criteria
Covered when ALL of the following are met
Preserves original nested AND logic across risk and impairment elements.
inv-02: Continued Stay Criteria
Continued stay is appropriate when ALL of the following are documented
Requires ongoing documentation and treatment plan review.
inv-03: Discharge Readiness Criteria
Discharge when ALL of the following are met or satisfactory arrangements are in place
Discharge planning begins at admission and includes specific documentation and notification requirements.
Admission to a Behavioral Health Residential Facility (BHRF) must not be used as a substitute for non-clinical or inappropriate purposes. Specifically, BHRF placement is not appropriate as an alternative to detention or incarceration, nor solely to ensure community safety when a member's behaviors reflect primarily conduct disorder without documented risk or serious functional impairment. It also must not be used simply to provide housing, shelter, supervision, or permanency placement, nor when less restrictive behavioral health alternatives are available and acceptable to the member or health care decision maker. Finally, BHRF admission is not an appropriate intervention for elopement or wandering behaviors that are unrelated to the individual's behavioral health condition.
Provider Requirements and Documentation
Prior authorization: show attempts/unavailability of less restrictive care and need for 24‑hour care
Document and submit evidence that less restrictive treatment options were attempted or were unavailable, and that the member requires 24‑hour behavioral health care and supervision to develop coping skills for safe community living. Include completed pre-admission assessments and treatment plan information supporting the need for admission and continued stay.
- Evidence that behavioral health treatment in a less restrictive level of care (e.g., IOP, Partial Hospitalization Program) has not been successful or is not available.
- Documentation of need for 24‑hour behavioral health care and supervision to develop adequate coping skills.
- Include pre‑admission assessment and treatment plan reviews to support authorization.
Step‑up requirement: failure or unavailability of IOP/PHP before BHRF
Provide documentation that less restrictive levels of care (for example, Intensive Outpatient Program or Partial Hospitalization Program) were attempted and failed or were not available prior to requesting BHRF admission.
- Explicit evidence that IOP/PHP were provided and did not achieve stabilization, or documentation that these options were not available.
Required documentation: pre‑admission assessment, diagnosis, recent risk and functional impairment, and regular treatment plan reviews
Include a comprehensive pre‑admission assessment and ongoing documentation to support admission and continued stay: diagnosis, recent evidence of risk and functional impairment, current treatment plan with regular reviews, and documentation of progress or regression toward goals.
- Pre‑admission assessment showing diagnosed behavioral health condition and recent evidence of at least one area of significant risk of harm and one area of serious functional impairment.
- Current treatment plan with regular reviews that includes review of services provided, progress toward goals, assessment of risk/functional impairment, availability of less restrictive supports, and adjustments to interventions.
- Documentation of treatment interventions, frequency, crisis/safety planning, and revised discharge plan to justify continued stay.
Exclusionary uses that will lead to denial
Do not request or authorize BHRF admission when it is being used as an alternative to detention or incarceration, as housing/shelter/permanency, or primarily for conduct disorder without evidence of risk or functional impairment; such uses are exclusionary and will result in denial.
- Admission is excluded if used as an alternative to detention or incarceration.
- Admission is excluded when the purpose is safe housing, shelter, supervision, or permanency placement.
- Admission is excluded for primarily conduct disorder behavior without presence of risk or functional impairment.
Background and Context
Behavioral Health Residential Facilities (BHRF) provide 24-hour behavioral health care for members whose clinical needs cannot be safely or effectively managed in outpatient, intensive outpatient (IOP), or partial hospitalization settings. The purpose of BHRF care is to stabilize significant risk or serious functional impairment, improve self-care and daily functioning, and prepare the member for a safe step-down to less restrictive services. Admission is intended when members require continuous supervision and therapeutic services to address documented risk behaviors and functional deficits and when less restrictive treatment options have been unsuccessful, unavailable, or clinically insufficient.
Key Definitions
Residential / BHRF Level-of-Care Criteria
inv-12: Residential / BHRF
Level-of-care criteria for admission/placement
Reflects residential/BHRF level-of-care requirements.
Treatment and Medication Management
inv-13: Medication management
Requirement/criteria for medication oversight during stay
Specific medication administration barrier noted.
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