CurrentBlue Cross Blue Shield - MichiganPolicy N/A

Partial Hospitalization Program (PHP) and Intensive Outpatient Program (IOP) coverage criteria for feeding and eating disorders

Specifications for partial hospitalization programs (PHP) and intensive outpatient programs (IOP) treating feeding and eating disorders for Blue Cross Blue Shield of Michigan and affiliated products; defines program requirements, ancillary services, and prior authorization rules for providers and facilities.

Policy Summary

PayerBlue Cross Blue Shield - Michigan

PolicyPartial Hospitalization Program (PHP) and Intensive Outpatient Program (IOP) coverage criteria for feeding and eating disorders

Policy CodePolicy N/A

Change TypeNo material clinical or coverage changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization for PHP by submitting requests electronically or by phone and ensure medical necessity documentation is met.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5 days/weekMinimum PHP frequency/duration

3 days/weekTypical IOP frequency/duration

0913/0912PHP intensity codes

90 minMax session duration

Annual

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Coverage Criteria for PHP and IOP

Coverage criteria for PHP and IOP

Covered when facility meets program requirements and medical necessity criteria are met.

Facility and program requirements: Facility must be a hospital or state-licensed and accredited freestanding outpatient psychiatric care facility; for PHP the facility must be approved by Blue Cross/BCN as a hospital or meet outpatient psychiatric care facility requirements.

See facility participation and clinical program requirements (chunks 3, 23).

PHP minimum delivery: PHP must be provided a minimum of 5 days per week for 5-6 hours per day (recommended 8 hours/day for eating disorders); psychiatric evaluation within 24 hours of admission; psychosocial assessment on day 1; medication reconciliation on day 1; clinical assessment/review at least daily; individual therapy 1x/day; group therapy 2x/day; family therapy 1-2x/week; expressive/mindfulness/activities 1x/day.PHP: 5 days/week, 5-6 hrs/day (recommended 8 hrs/day for eating disorders)

See chunks 4 and 6 for required elements and session frequency.

IOP minimum delivery: IOP must provide treatment typically at least 3 days per week for 3 hours per day; psychosocial assessment at first visit; substance use evaluation by second visit if indicated; medication reconciliation at first visit; individual therapy 1x/week; group therapy 3x/week; family therapy 1x/week (may substitute for individual therapy); psychoeducation 3x/week; expressive therapies/mindfulness/activities at least 1x/week; psychiatric or medication evaluation as needed.IOP: >=3 days/week, >=3 hrs/day

See chunks 14 and 15 for required elements and specialty requirements for eating disorders.

Eating disorder specialty services: For feeding and eating disorders programs the PHP/IOP must provide intake physical exam (may accept PCP exam), physiologic monitoring by a registered nurse including continuous monitoring devices as needed, nutritional assessment and ongoing sessions by a registered dietician, meal delivery and supported meals/exposure therapy, and behavioral counseling integrated into the program.

See chunks 8 and 15 for nutrition and RN monitoring requirements.

Eligibility and covered services

Covered when ALL of the following are met

Facility participation: For providers in Michigan: the provider must participate with Blue Cross or BCN or both. For providers outside Michigan: the provider must participate with their local Blue Cross Blue Shield plan. Providers must verify each member's benefits and eligibility via the provider portal.

See chunk 21 for participation and benefit verification requirements.

Covered services: Reimbursable services include services provided by facility staff such as individual psychotherapeutic treatment, family counseling, group psychotherapeutic treatment, and prescribed drugs given by the facility in connection with the member's treatment plan.

See chunk 22 for the list of eligible program services.

Services are eligible only when provided in an approved setting. A partial hospitalization program (PHP) must be provided in a hospital or a freestanding, state-licensed and accredited outpatient psychiatric care facility. Before providing PHP for Blue Cross or BCN members, the provider must either be approved by Blue Cross or BCN as a hospital or, for members with mental health disorders, meet the Blue Cross and BCN requirements to qualify as an outpatient psychiatric care facility.

The policy lists specific exclusions. Not payable are items such as staff consultations required by a facility's rule, marital counseling, services by providers who do not participate with Blue Cross/BCN in Michigan (or with the local Blue Cross Blue Shield plan outside Michigan), and a PHP admission without prior authorization. Also excluded are services not focused on improving functioning, court-ordered services, milieu therapies (for example wilderness programs or supportive housing), custodial or diversional care, and extra charges for sessions longer than 90 minutes (group or individual). Repeated redundant services and nonmedical enrichment modalities (art, music, equine, yoga/movement therapies, etc.) are not payable separately though they may be included as part of a treatment program.

Prior authorization determinations for PHP are made using Blue Cross Behavioral Health medical necessity criteria. Providers must submit PHP prior authorization requests electronically or by phone and the request must meet the criteria for medical necessity, use and quality. If the requested services do not meet those medical necessity criteria, the prior authorization may be denied.

Services or continued stays that lack appropriate clinical documentation or justification may be deemed not medically necessary and denied. Examples include continued stay without documentation of a thorough evaluation, an individualized treatment plan, and convincing justification, repeated or redundant services without clinical rationale, admissions or continued stays initiated for socioeconomic/home reasons, services after physician discharge, and care provided when the member is not engaged or participating after a reasonable period.

Coding and Visit Parameters

PHP intensity level codesmixed

0913	PHP intensive level: 21+ hours/week
0912	PHP less intensive level: 20 hours or less/week

Ancillary procedure codesCPT

90792

Psychiatric diagnostic evaluation with medical services (listed as example procedure code)

PHP weekly hours threshold — Intensive vs Less intensive

Intensive level (0913)21 hours or more per week (>=21 hrs/week)

Less intensive level (0912)20 hours or less per week (<=20 hrs/week)

Typical deliveryProvided on 5 days per week

Session frequency and duration — PHP and IOP

PHP frequency & durationMinimum 5 days/week, 5-6 hours/day (recommended 8 hours/day for eating disorders)

IOP frequency & durationTypically at least 3 days/week for 3 hours/day

Provider Responsibilities, Authorization, and Documentation

Prior Authorization

Prior Authorization Required for PHP

Prior authorization is required for PHP. Providers must submit prior authorization requests electronically or by phone and meet Blue Cross/BCN medical necessity criteria. If prior authorization is not obtained, participating/in‑network facilities cannot bill the member for the admission and services; nonparticipating/out‑of‑network facilities may require the member to pay.

Submit requests electronically or by phone
Determinations based on Blue Cross Behavioral Health medical necessity criteria (see Commercial and Medicare Advantage prior auth pages)
If prior auth absent: participating facilities cannot bill member; nonparticipating facilities may hold member financially responsible

Prior Authorization

IOP Prior Authorization Rules and Exceptions

IOP generally does not require prior authorization. Exception: BCN commercial and BCN Advantage members require prior authorization for IOP services rendered outside Michigan (excludes Blue Elect Plus coverage).

Background and Scope

Partial Hospitalization Programs (PHP) deliver a daily psychosocial milieu that combines multiple therapy modalities — group, individual and family therapy; expressive therapies; psychoeducation; and behavioral counseling — with nursing and medical oversight as needed. PHP is delivered in either a hospital or a state-licensed, accredited freestanding outpatient psychiatric care facility and is intended for members who require intensive daily psychosocial treatment and monitoring.

PHP for feeding and eating disorders includes additional specialty elements such as physiologic monitoring by a registered nurse, nutritional assessment and ongoing registered dietitian involvement, supported meals and meal-exposure therapy, and other services integral to medical and nutritional stabilization.

Definitions

PHP — definition and included therapies

DefinitionPartial Hospitalization Program (PHP): daily psychosocial milieu treatment including group, individual, family, expressive therapies, psychoeducation and other therapies as primary modalities.

Required clinical elementsPsychiatric evaluation within 24 hours of admission; psychosocial assessment day 1; medication reconciliation day 1; daily clinical assessment.

Included therapiesGroup therapy, individual therapy, family therapy, expressive/mindfulness/activities therapy, psychoeducation, supported meals and RN monitoring (for eating disorders)

IOP — definition and typical schedule

DefinitionIntensive Outpatient Program (IOP): treatment more intensive than traditional outpatient therapy but less intensive than PHP; for individuals needing skill-building and symptom management.

Typical schedule

Level-of-Care: PHP and IOP Criteria

Partial Hospitalization Program (PHP)

Admission to PHP (initial criteria): Member requires intensive daily psychosocial treatment for feeding or eating disorders with supervision and multi-modal therapies that cannot be safely or effectively provided in a lower level of care; facility meets PHP requirements; prior authorization obtained when applicable; documentation includes psychiatric evaluation within 24 hours and psychosocial assessment on day 1.

See chunks 4 and 6 for elements and prior auth rules (chunk 11).

Admission to PHP (eating disorder specifics): Member requires RN physiologic monitoring, nutritional assessment and supported meals as part of treatment; program must provide ongoing RD sessions and behavioral counseling integrated into daily care.

See chunks 8 and 15 for required eating-disorder services.

Continued PHP stay (continuation criteria): Ongoing daily clinical assessments documenting clinical improvement or an ongoing need for intensive services; continued documentation of therapies, RN monitoring, nutrition services and care coordination as applicable to the member's diagnosis.

Accepted Treatment Modalities and Services

Multimodal behavioral therapies (PHP/IOP)

Therapies included in PHP/IOP: Group therapy, individual therapy, family therapy, expressive therapies, psychoeducation, behavioral counseling, exposure therapy (including supported meals), and RN physiological monitoring (for eating disorders) are included in PHP/IOP programs and part of program reimbursement.

See chunks 2, 6, 8, 14 and 15 for modality lists and frequency expectations.

Program-delivered ancillary services: Ancillary supports such as toxicology screening, self-help/12-step groups, care coordination, and ongoing dietician-delivered nutritional care are part of the program and reimbursable when included in the treatment plan.

See chunks 6, 8 and 15 for examples of ancillary services.

Nonmedical modalities: Nonmedical services (art, music, equine, yoga, movement therapies and similar) may be included in a treatment program but are not payable separately.

See chunk 25 for nonmedical services payment guidance.

Visit Duration and Reimbursement Limits

PHP / IOP — standard visit length and weekly frequency

Standard visit length (PHP)5-6 hours per day (minimum) — recommended 8 hours/day for eating disorders

Standard weekly frequency (PHP)Minimum 5 days per week

Standard visit length & frequency (IOP)Typically 3 hours per day, at least 3 days per week

Group or individual psychotherapy — maximum reimbursable duration

Maximum reimbursable durationNo separate payment for group psychotherapy lasting more than 90 minutes (extra charges not payable)

Individual psychotherapy limitNo separate payment for individual therapy lasting more than 90 minutes (extra charges not payable)

Policy Summary

PayerBlue Cross Blue Shield - Michigan

PolicyPartial Hospitalization Program (PHP) and Intensive Outpatient Program (IOP) coverage criteria for feeding and eating disorders

Policy CodePolicy N/A

Change TypeNo material clinical or coverage changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization for PHP by submitting requests electronically or by phone and ensure medical necessity documentation is met.

SourceLink

On This Page

PHP daily therapy expectations

Includes individual therapy 1x/day and group therapy (2 sessions/day)

Stabilized BMI range

Minimum stabilized BMI21.25 BMI

Maximum stabilized BMI35.26 BMI

Reporting metricPrograms should report starting BMI and percentage progressing to stabilized weight within this range

IOP — no prior authorization required (general rule)

Exception — BCN commercial & BCN Advantage: prior authorization required for out‑of‑state IOP services

Blue Elect Plus members are excluded from that BCN out‑of‑state requirement

Documentation Required

Initial and Ongoing Clinical Documentation Requirements

Facilities must provide and retain initial and ongoing clinical documentation to support medical necessity and continued stay, including timely psychiatric and psychosocial assessments, medication reconciliation/review, and daily clinical assessments.

Psychiatric evaluation within 24 hours of PHP admission (face‑to‑face or virtual)
Psychosocial assessment on day 1 (PHP) / at first visit (IOP)
Substance use evaluation within first 2 days (PHP) or by second IOP visit, if indicated
Medication reconciliation on day 1; medication review at least weekly (daily advised)
Clinical assessment/review at least daily for PHP; psychiatric/medication evaluation as needed for IOP
Document individualized treatment, regular progress notes, and justification for continued stay — lack of thorough evaluation/individualized treatment risks denial

Note

Annual Reporting Requirements for PHP and IOP

Programs must collect and report specified annual data elements for PHP and IOP feeding/eating disorder services to support outcomes analysis and quality monitoring.

Members served: volume, diagnosis, age range, average length of stay (ALOS), disposition/aftercare
Member‑reported outcomes: eating disorder symptom measures (e.g., EDE‑Q or similar), quality of life (e.g., EDQOL or similar), risk assessment (e.g., C‑SSRS or similar), depressive symptom impact (PHQ‑9)
Other outcomes: anxiety measures (e.g., GAD‑7 or STAI), patient satisfaction (medical, nursing, dietary, therapy)
Weight outcomes for eating disorders: starting BMI; percentage of members progressing toward stabilized weight within specified BMI range

Billing Rule

Ancillary/Supplemental Services and Billing Guidance

Ancillary and supplemental services may be provided to support PHP/IOP treatment but some services are not separately payable. Ensure documentation supports medical necessity and that services billed separately are appropriate and not duplicative of program components.

Complex chronic care management, family partnership meetings, coordination/case management
Psychotherapy and medical reviews: E/M with psychotherapy add‑on, psychiatric diagnostic evaluation with medical services (90792), specialty psychotherapy not included in program (e.g., ERP, DBT, EMDR)
Psychological testing when clinically indicated
Peer support services: mentorship, advocacy, system navigation and coping/resource connection
Nonmedical/enrichment services (art/music/yoga/equine/other experiential therapies) are generally nonmedical and not payable separately; may be included as part of a treatment program but not billed separately
Avoid repeated or redundant services (e.g., repeated physical exam/report within 3 months) — repeated services without reason risk denial

Denial Risk

Consequences for PHP Admissions Without Prior Authorization

A PHP admission that occurs without prior authorization is specifically listed as not covered. Providers should obtain prior authorization before admission to avoid denial and billing restrictions.

A PHP admission without prior authorization before the admission is not covered
Participating facilities cannot bill members for such admissions; nonparticipating facilities may require member payment

Typically at least 3 days per week for 3 hours per day; includes psychosocial assessment at first visit and medication reconciliation at first visit.

Included therapiesIndividual therapy (1x/week), group therapy (3x/week), family therapy (1x/week), psychoeducation and expressive therapies as specified.

See chunks 4, 6 and 8 for required ongoing components and frequency.

Intensive Outpatient Program (IOP)

Admission to IOP (initial criteria): Member requires interventions for moderate to severe behavioral health disorders to improve functioning, skill-building, or symptom management that are not adequately addressed by standard outpatient therapy; facility provides IOP services as specified (psychosocial assessment at first visit, medication reconciliation at first visit, substance use evaluation by second visit if indicated).

See chunk 14 for IOP admission and assessment timing; see chunk 18 for prior authorization exception rules.

IOP treatment components: IOP must provide individual therapy (1x/week), group therapy (3x/week), family therapy (1x/week, may substitute for individual), psychoeducation (3x/week), expressive/mindfulness activities (>=1x/week), toxicology/self-help groups and care coordination as needed.IOP: >=3 days/week, >=3 hrs/day

See chunk 14 for general IOP requirements and chunk 15 for feeding/eating-disorder-specific additions.

Continued IOP stay (continuation criteria): Documentation of ongoing group, individual and psychoeducation sessions and measurable clinical progress toward treatment goals; RN monitoring and nutrition services when treating feeding/eating disorders as applicable.

See chunks 14 and 15 for required elements and frequency.

PHP and IOP combined criteria

Cross-cutting admission, authorization, and discharge considerations for both PHP and IOP.

Prior authorization and utilization management: PHP requires prior authorization; providers must submit requests electronically or by phone and meet 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. If prior authorization is not obtained for PHP, the admission will not be paid and participating facilities cannot bill the member.

See chunks 11 and 18 for prior authorization rules and consequences.

Provider network and billing: Services provided by non-participating providers (in Michigan those not participating with Blue Cross/BCN; outside Michigan those not participating with local BCBS plan) are not eligible for reimbursement; participating providers must verify member benefits and eligibility prior to admission.

See chunk 21 and chunk 11 regarding reimbursement and billing consequences.

Continued stay documentation and discharge: Continued stay requires documentation of a thorough evaluation, individualized treatment plan, regular clinical reviews and convincing justification for ongoing intensive care; absence of documentation or lack of engagement may render continued stay not medically necessary and result in denial of payment.

See chunk 25 for examples of services/stays considered not medically necessary.

Psychotherapy, facility-administered medications

Psychotherapy and facility-administered medications: Individual, family and group psychotherapy provided by facility staff, and prescribed drugs administered by the facility in connection with the member's treatment plan, are eligible for reimbursement when documented as part of the program.

See chunk 22 for covered services.

Limitations on separate payment: Services that are nonmedical or enrichment-focused are not payable separately though they may be included within program reimbursement; repeated or redundant services and services provided without justification are not covered separately.

See chunk 25 for exclusions and not medically necessary examples.

Billing implicationSessions exceeding 90 minutes should not result in separate/additional reimbursement