This document specifies clinical and operational standards for PHP and IOP services applicable to Blue Cross and Blue Shield of Michigan and Blue Care Network commercial and Medicare Plus Blue (Medicare Advantage) members.
PHP clinical and operational standards: PHP must be provided in a hospital or a freestanding state-licensed and accredited outpatient psychiatric care facility; providers must be approved by Blue Cross/BCN as a hospital or meet facility qualification requirements for outpatient psychiatric or substance use disorder treatment. PHP is required to be delivered a minimum of 5 days per week with program-level frequency/duration guidance in the document. Facilities must provide psychiatric evaluation within 24 hours of admission, psychosocial assessment on day 1, substance use evaluation within the first two days, medication reconciliation on day 1, regular medication review, daily clinical assessment, individual therapy (1 session/day), group therapy (2 sessions/day), family therapy (1–2 times weekly), expressive/mindfulness/activities therapy (1 session/day), toxicology screening as needed, care coordination, and subacute detoxification as necessary.
PHP service levels (operational thresholds): Intensive level (code 0913)—services for 21+ hours/week on 5 days/week for 5–6 hours/day; Less intensive level (code 0912)—services for 20 hours or less/week on 5 days/week for ~4 hours/day.
IOP clinical and operational standards: IOP typically provides treatment at least 3 days/week for 3 hours/day. Required elements include psychosocial assessment at first visit, substance use evaluation by second visit, medication reconciliation at first visit, individual therapy (1 session/week), group therapy (3 sessions/week), family therapy (1 session/week), psychoeducation (3 sessions/week), expressive therapies/mindfulness at least once weekly, psychiatric/medication evaluation as needed, toxicology screening/self-help groups as needed, care coordination, and subacute detoxification as necessary.
Prior authorization and participation: PHP requires prior authorization submitted electronically or by phone and determinations use Blue Cross Behavioral Health medical necessity criteria. IOP generally does not require prior authorization except BCN commercial and BCN Advantage members require prior authorization for IOP services rendered outside Michigan (not applicable to Blue Elect Plus members). Providers in Michigan must participate with Blue Cross or BCN (outside Michigan must participate with the local BCBS plan) to be eligible for reimbursement.
Topics covered in this policy include: frequency/duration, required assessments and clinical documentation, therapy session minimums, facility licensing and participation requirements, and detoxification coverage conditions.