Treatment Foster Care (TFC) — Admission, Continued Stay, and Discharge Criteria
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Defines clinical criteria and process for admission, continued authorization, and discharge from Treatment Foster Care for child and adolescent members of BCBSAZ Health Choice. Applies to providers and Child and Family Teams coordinating care and prior authorization requests.
No material clinical or coverage changes in this revision.
Coverage Criteria for Treatment Foster Care (TFC)
inv-01: Initial Admission
Covered when ALL of the following are met for admission
Admission criteria
- Special consideration risk factors: Member has two or more of: multiple out-of-home placements; history of disruption from a foster home due to behaviors; one or more hospitalizations for a behavioral health condition in the last year; chronic suspensions from school/day programming; adoption disruption or potential adoption disruption; significant trauma history or trauma-related diagnosis; placed or at-risk of placement in a congregate care setting; at-risk of placement disruption due to behaviors requiring higher supervision; identified as a potential victim of trafficking; criminal justice involvement; co-occurring developmental disability; at-risk of being removed from home by Department of Child Safety due to behavioral concerns.2+
inv-02: Continued Stay
Continued stay covered when ALL the following are met
inv-03: Discharge Criteria
Discharge is appropriate when ANY of the following are present
Member is not eligible for Treatment Foster Care (TFC) if they require or meet clinical criteria for a higher level of care. Documentation must demonstrate that the member's assessed needs do not meet criteria for more intensive services before TFC can be approved.
TFC is not appropriate when either: 1) the member meets criteria for a higher level of care, or 2) the parent/guardian does not agree to the TFC prior authorization request. Lack of parental/guardian agreement is a basis to deny or discontinue TFC authorization.
TFC Level of Care Criteria
Coding and Functional Thresholds
Provider Actions, Prior Authorization, and Documentation
Prior Authorization Required
Prior authorization and admission recommendation must be initiated through the Child and Family Team (CFT) process. An interim service plan coordinated through Integrated Rapid Response may be used to establish the recommendation for admission prior to a full CFT. Blue Cross Blue Shield of Arizona (BCBSAZ Health Choice) will accept the level-of-care recommendation determined by CALOCUS/ESCII to demonstrate sufficient necessity for admission to Therapeutic Foster Care (TFC) and will not require an additional prior authorization for at least the first 30 days when that recommendation is documented.
- Prior authorization and admission recommendation source: Child and Family Team (CFT) process or interim service plan via Integrated Rapid Response
- BCBSAZ accepts CALOCUS/ESCII recommended level of care as sufficient necessity for admission to TFC for at least 30 days
Required Documentation
The assessment must document a diagnosed behavioral health condition with specific symptoms and behaviors to be treated and include evidence of moderate functional and/or psychosocial impairment (e.g., CALOCUS/ESCII score or other clinical indicators). The assessment and the individualized service plan (ISP) must be reviewed and signed by a behavioral health professional (BHP). Parent/guardian agreement to the TFC prior authorization request is required. Documentation should also note that the member does not meet criteria for a higher level of care.
- Required documentation: behavioral health assessment with diagnosis, symptoms/behaviors to be treated
- CALOCUS/ESCII score or other clinical indicators demonstrating moderate impairment
- ISP reviewed and signed by a BHP
- Parent/guardian agreement to TFC PA request
- Statement that member does not meet criteria for a higher level of care
Step-down Assessment
Step-down assessment must demonstrate that the member has not improved or is not reasonably expected to improve with a less intensive level of care, or that appropriate community-based treatment is unavailable and therefore a more intensive level of care is warranted. Special consideration should be documented for children meeting two or more high-risk factors (examples below) when assessing step-down readiness.
- Step-down assessment criteria: member has not improved or cannot be expected to improve with less intensive care, OR community-based treatment is unavailable
- Document special considerations when two or more high-risk factors are present (e.g., multiple out-of-home placements, prior hospitalizations for behavioral health, chronic suspensions, adoption disruption risk, significant trauma history, at-risk of congregate care placement, co-occurring developmental disability, DCS removal risk)
Key Definitions
Background
Treatment Foster Care (TFC) is an intensive community-based behavioral health placement for children and adolescents whose diagnosed behavioral health condition results in moderate functional impairment as evidenced by CALOCUS/ECSII or other clinical indicators. The impairment must either not have improved or not be reasonably expected to improve with a less intensive level of care, or appropriate community-based treatment must be unavailable, to justify TFC admission. Parent/guardian agreement to the TFC prior authorization request and confirmation that the member does not meet criteria for a higher level of care are required for approval.
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