CurrentBlue Cross Blue Shield - North CarolinaPolicy N/A

Partial Hospitalization Program (PHP) Authorization Request / Coverage Criteria

Form and requirements for submitting prior authorization requests for Partial Hospitalization Program (PHP) behavioral health services to Blue Cross Blue Shield of North Carolina Medicare plans; affects providers seeking authorization for PHP admission, certification, and recertification for members.

Policy Summary

PayerBlue Cross Blue Shield - North Carolina

PolicyPartial Hospitalization Program (PHP) Authorization Request / Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the authorization request form (including provider NPI) via the Blue E Authorization Portal or fax to 336-794-1557.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

20 hrs/wkminimum PHP service intensity required for initial certification

Day 18recertification required by

30 daysrecertification frequency

336-794-1557submission fax

G0129, G0176, G0177, G0410, G0411, 90837

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Coverage Criteria for PHP

inv-01: Initial Certification — Initial Psychiatric Evaluation/Certification — Covered when ALL of the following are met

Initial Psychiatric Evaluation/Certification — Covered when ALL of the following are met

Initial Certification Requirements: The certification identifies the diagnosis and psychiatric need for partial hospitalization; the individual requires services for a minimum of 20 hours per week and would require inpatient psychiatric care if PHP services were not provided; services are furnished while the individual is under the care of a physician.

Eligibility Requirements: Patient has been discharged from an inpatient hospital treatment program and PHP is in lieu of continued inpatient treatment with evidence of need for an acute, intense, structured combination of services; OR patient would be at reasonable risk of requiring inpatient hospitalization without PHP. Patient has the cognitive and emotional ability to participate in active treatment and tolerate PHP intensity; does not require 24-hour inpatient supervision and has adequate personal and community-based supports; is not an imminent danger to self or others. Documentation of all personal and community-based support systems is required.>=20 hours/week

Services furnished under physician care.

inv-02: Recertification/Extension — Recertification/Continuation of Stay — Covered when ALL of the following are met

Recertification/Continuation of Stay — Covered when ALL of the following are met

Timing: Recertification is required as of the 18th calendar day following admission to the PHP; subsequent recertifications at intervals established by the provider but no less frequently than every 30 days.recert by day 18, then >= every 30 days

Clinical Recertification Requirements: Recertification must be signed by the treating physician who knows the patient's response to treatment. Documentation must state that the individual would require inpatient psychiatric care in the absence of continued PHP stay; list the patient's response to therapeutic interventions provided by the PHP; list ongoing psychiatric symptoms that continue to place the patient at risk of hospitalization; and provide treatment goals for coordination of services to facilitate discharge. Services must be furnished while the individual is under the care of a physician.

Additional clinical documentation and medical records may be requested to support responses.

Per the procedure code guidance on the authorization form, please note that 'H' and 'S' codes are not Medicare-covered codes. Providers should not submit H- or S-series CPT codes for Medicare members when requesting authorization for Partial Hospitalization Program (PHP) services; use only the listed G- and CPT codes on the form.

Coding and Service Intensity

Procedure Codes listed on formCPT

G0129	Listed G code for PHP per diem (form selection)
G0176	Listed G code for PHP per diem (form selection)
G0177	Listed G code for PHP per diem (form selection)
G0410	Listed G code for PHP per diem (form selection)
G0411	Listed G code for PHP per diem (form selection)
90837	Psychotherapy 60 minutes (note: can only be used in conjunction with G code AND if primary diagnosis is substance use disorder)

inv-05: Minimum weekly PHP hours

Minimum weekly PHP hoursPatient requires services for a minimum of 20 hours per week

Context for thresholdThreshold applies to initial certification — individual would require inpatient care without PHP

Service oversightServices must be furnished while the individual is under the care of a physician

Provider Submission and Documentation Requirements

Prior Authorization

Prior Authorization Submission

Submit this authorization request form (including provider NPI) via the Blue E Authorization Portal or fax to 336-794-1557. Use for Blue Medicare HMO SM/PPO SM plans. Submission of this form is only a request for services and does not guarantee approval. Incomplete forms may delay processing; missing NPI will block processing.

Fax: 336-794-1557
Blue E Authorization Portal
All providers must include their NPI on the form

Denial Risk

Authorization Request Processing Risk

Incomplete or missing information on the authorization request may delay processing and does not guarantee approval. All providers, including Blue Cross NC providers, must provide their NPI# below; omission of the NPI will block processing.

Submission does not guarantee approval

Partial Hospitalization (PHP) Level-of-Care Criteria

inv-12: Partial Hospitalization (PHP) — Level of care criteria (top-level nodes as specified in source)

Level of Care Criteria for Partial Hospitalization (PHP): Patient requires an intensive, structured PHP to maintain function and prevent relapse or hospitalization and would require inpatient psychiatric care without PHP; patient is able to participate in active treatment and tolerate intensity; patient does not require 24-hour supervision and has supports to remain outside inpatient setting; documentation of supports is required; services are furnished while the individual is under the care of a physician.>=20 hours/week

Service Intensity and Billing: PHP provides intensive, structured services delivered per diem; minimum of 20 hours per week of services is required for admission/certification.>=20 hours/week

Only one (1) per-diem unit for PHP on a facility claim is allowed per date of service.

Multidisciplinary Services Provided in PHP

inv-13: PHP multidisciplinary services — Describes required multidisciplinary services (1 top-level node)

Therapies: PHP includes a combination of facility, professional, ancillary, and other services rendered per diem; 90837 may be used only in conjunction with a G code and when the primary diagnosis is a substance use disorder.

Only one per-diem unit allowed per date of service on facility claim; 'H' and 'S' codes are not Medicare-covered codes.

Visit and Unit Limits

inv-14: Per-diem PHP facility unit

Per-diem unit ruleOnly one (1) per-diem unit for PHP on a facility claim is allowed per date of service

Scope of per-diem unitPer-diem unit includes all facility, professional, ancillary, and other services rendered to the member at the site

Code guidance'H' and 'S' codes are not Medicare-covered codes

Definitions

inv-11: PHP — Partial Hospitalization Program (definition)

DefinitionPartial Hospitalization Program (PHP): an intensive, structured combination of services provided as an alternative to inpatient care for individuals who require acute, intensive treatment but do not need 24‑hour supervision

Participation requirementPatient must have the cognitive and emotional ability to participate in active treatment and tolerate the intensity of PHP

Risk criterionPHP is appropriate when the patient would be at reasonable risk of requiring inpatient hospitalization in the absence of PHP

Support requirementPatient must not require 24‑hour supervision and must have adequate personal and community-based support systems documented

Background

Partial Hospitalization Programs (PHP) provide intensive outpatient psychiatric treatment as an alternative to inpatient care for individuals who require a structured combination of services but do not need 24-hour inpatient supervision. Clinical documentation supporting PHP admission must demonstrate that the member would be at reasonable risk of hospitalization without PHP, can participate in and tolerate the program’s intensity, and has adequate personal and community supports to remain outside an inpatient setting.