CurrentBlue Cross Blue Shield - MainePolicy C-19002

Partial Hospitalization Program and Intensive Outpatient Program Services — Facility

Governs facility reimbursement for PHP and IOP services for commercial members, outlining billing, allowed units per date of service, and services included or excluded from separate reimbursement.

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyPartial Hospitalization Program and Intensive Outpatient Program Services — Facility

Policy CodePolicy C-19002

Change TypeNo material change

Effective DateJul 23, 2025

Next Review DateN/A

Key ActionEnsure services meet authorization and medical necessity guidelines and submit correct billing codes to avoid recoupment or denial.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1 unit/dayAllowed units per date of service

>=20 hrsPHP minimum hours/week

>=9 hrsIOP minimum hours/week

All-inclusiveReimbursement scope

Facility Reimbursement Criteria for PHP and IOP

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Facility reimbursement criteria for PHP/IOP

Facility reimbursement rules for PHP and IOP:

Allow reimbursement for one (1) unit per date of service for either Partial Hospitalization Program (PHP) or Intensive Outpatient Program (IOP) services (not both).

Facilities must report the appropriate PHP or IOP specific revenue code and HCPCS code on the UB-04 for reimbursement; standard correct coding applies.

Reimbursement for PHP or IOP is all-inclusive of laboratory; room and board (including services rendered by facility employees); equipment; pharmaceuticals; and other services incidental to the stay.

Separate reimbursement is not allowed for ancillary services provided by an external laboratory, including pathology testing, laboratory services, specimen collection, and related supplies.

Service intensity minimums: PHP requires a minimum of 20 hours per week of therapeutic services; IOP requires a minimum of 9 hours per week of therapeutic services. Multiple therapeutic services are expected for each date of member participation (for PHP includes physicians or other qualified health care professionals, nursing services, individual, group, family therapies and educational services).

Under Per Diem, Per Unit, Per Visit, or Percentage Rate methodologies, all other units billed will be denied unless provider, state, or federal contracts or requirements indicate otherwise.

Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis; determination of coverage under a member's benefit plan is not a guarantee of reimbursement and improper coding/billing may result in recovery, recoupment, rejection, or denial of payment.

Billing and Service Intensity Guidance

Billing guidancemixed

No codes listed

Service intensity thresholds — PHP/IOP

PHP minimum weekly therapeutic hoursPartial Hospitalization Program (PHP) requires a minimum of 20 hours per week of therapeutic services.

IOP minimum weekly therapeutic hoursIntensive Outpatient Program (IOP) requires a minimum of 9 hours per week of therapeutic services.

ApplicabilityService intensity minimums apply to facility reimbursement for PHP and IOP and are part of the criteria for one unit per date of service.

Authorization and Medical Necessity Requirements

Prior Authorization

Obtain authorization and ensure medical necessity; follow coding guidelines

Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis, as well as to the member's state of residence. Determination of coverage under a member's benefit plan is not a determination that you will be reimbursed; if appropriate coding/billing guidelines or current reimbursement policies are not followed, the plan may recover/recoup payment or reject or deny the claim.

Use industry-standard CPT, HCPCS, and revenue codes and ensure services billed are fully supported in the medical record or office notes.
Follow applicable provider, state, federal, or CMS mandates; contract or regulatory requirements may supersede this policy.

Program Definitions

IOP (Intensive Outpatient Program) definition

TermIntensive Outpatient Program (IOP)

DefinitionStructured, short-term treatment modality that provides a combination of individual, group, and family therapy; an alternative to inpatient or partial hospital care; intended for patients who require a minimum of 9 hours of therapeutic services per week.

Intensity compared to other levelsMore intensive than outpatient day treatment and less intensive than a Partial Hospitalization Program (PHP).

PHP (Partial Hospitalization Program) definition

TermPartial Hospitalization Program (PHP)

DefinitionStructured, short-term treatment modality and an alternative to acute inpatient care offering intensive, coordinated multidisciplinary clinical and diagnostic services under physician direction; intended for patients who require a minimum of 20 hours per week of therapeutic services with multiple therapeutic services expected each date of participation.

Reimbursement noteFacilities should report the appropriate PHP revenue and HCPCS codes on UB-04; reimbursement is all-inclusive of laboratory, room and board, equipment, pharmaceuticals, and other incidental services.