CurrentBlue Cross Blue Shield - NevadaPolicy C-19002

Partial Hospitalization Program and Intensive Outpatient Program Services — Facility

Reimbursement rules for facility delivery of PHP and IOP services, describing allowable billing units, included ancillary services, and coding/reporting expectations for Blue Cross Blue Shield - Nevada commercial plans.

Policy Summary

PayerBlue Cross Blue Shield - Nevada

PolicyPartial Hospitalization Program and Intensive Outpatient Program Services — Facility

Policy CodePolicy C-19002

Change TypeAdded all-inclusive ancillary languageclarified per-date unit limitation

Effective DateJul 23, 2025

Next Review Date

Key ActionEnsure services meet authorization and medical necessity guidelines; bill one unit per date of service for either PHP or IOP.

SourceLink

POLICY UPDATE CHANGES

Added all-inclusive and ancillary language from retired policy Expenses Included in Facility Charges (C-17001).

Clarified that reimbursement is limited to one unit per date of service for either PHP or IOP (not both).

1 unit/dayallowed reimbursement for PHP or IOP per date of service

>=9 hrs/wkminimum therapeutic services for IOP

>=20 hrs/wkminimum therapeutic services for PHP

All-inclusive

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Facility PHP and IOP Coverage Criteria

Facility PHP/IOP coverage criteria

Reimbursement and coverage criteria for facility-based PHP and IOP services.

Reimbursement is allowed for one (1) unit per date of service for either Partial Hospitalization Program (PHP) or Intensive Outpatient Program (IOP) — not both.

Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis and the member's state of residence.

Facilities must report the appropriate PHP or IOP‑specific revenue code and HCPCS code on a UB‑04 for reimbursement; standard correct coding and any applicable provider, state, or federal contract requirements apply.

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 inpatient or outpatient stay.

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

ALL of the following

Intensive Outpatient Program (IOP) — intended for patients who require a minimum of 9 hours of therapeutic services per week.
Partial Hospitalization Program (PHP) — intended for patients who require a minimum of 20 hours of therapeutic services per week; multiple therapeutic services are expected for each date of member participation (e.g., 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, any additional units billed beyond one per date of service will be denied unless provider, state, or federal contracts or requirements indicate otherwise.

Billing, Codes, and Service Hours

Facility billing requirementsHCPCS | Revenue

UB-04 revenue and HCPCS

Facilities should report the appropriate PHP or IOP specific revenue code and HCPCS code on a UB-04 for reimbursement.

IOP minimum weekly hours

Minimum weekly therapeutic hours9 hours per week

Treatment intensityMore intensive than outpatient day treatment and less intense than PHP

Service modalitiesCombination of individual, group, and family therapy

Care setting purposeAlternative to inpatient or partial hospital care for active psychiatric or substance-related illness

PHP minimum weekly hours

Minimum weekly therapeutic hours20 hours per week

Service intensity

Authorization, Medical Necessity, and Provider Responsibilities

Prior Authorization

Authorization and medical necessity required; one unit per date of service

Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis and the member's state of residence; reimbursement is allowed for one (1) unit per date of service for either PHP or IOP. Ensure prior authorization and documentation of medical necessity are obtained and maintained to support the single per‑date reimbursement unit.

Obtain and document authorization and medical necessity consistent with the member's state of residence.
Bill no more than one (1) unit per date of service for either Partial Hospitalization Program (PHP) or Intensive Outpatient Program (IOP).

Program Definitions

Intensive Outpatient Program (IOP)

DefinitionStructured, short-term treatment modality providing a combination of individual, group, and family therapy

Care roleAlternative to inpatient or partial hospital care for patients with an active psychiatric or substance-related illness

Intensity relative to other settingsMore intensive than outpatient day treatment and less intense than partial hospitalization (PHP)

Minimum hours requirementRequires a minimum of 9 hours per week of therapeutic services

Partial Hospitalization Program (PHP)

DefinitionStructured, short-term treatment modality and alternative to acute inpatient care offering intensive, coordinated multidisciplinary clinical and diagnostic services