Tennessee Health Link (THL) — Children and Adolescents: Medical Necessity Criteria
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Medical necessity criteria, eligibility, continuation, discharge, and exclusions for the Tennessee Health Link care coordination program for children and adolescents enrolled in BlueCare and TennCare Select.
No material clinical or coverage changes in this revision.
Coverage Criteria
Initial Eligibility (Functional-need pathway and diagnostic requirements)
Covered when ALL of the following are met
Includes episodic, recurrent, or persistent disorders
Functional impairment defined as disruption in social, behavioral, cognitive, communicative, or adaptive skills; includes episodic, recurrent, or continuous duration
Alternative Eligibility (Any two behavioral conditions)
Covered when ANY two of the following conditions apply
Service goal focused on recovery, maintaining baseline functioning, and preventing relapse to acute care
Exclusions from Tennessee Health Link include recent clinical instability or ongoing higher-level placements that make THL inappropriate. Specifically, individuals who have had a medication adjustment in the previous six (6) months due to instability of symptoms and who have developed additional conditions requiring further assessment, planning, linkage, monitoring, or follow-up are excluded.
Individuals who have had at least two psychiatrically driven presentations to an emergency department within the last six (6) months are excluded. Also excluded are those who demonstrate a pattern within the last six (6) months of failing to identify or access needed medical, educational, social, or other services; involvement with law enforcement or the juvenile justice system; involvement with the Department of Children’s Services; or disciplinary action with the local educational system.
Refusal of consent by the person with authority to consent to treatment excludes enrollment. Long-term residential placement is an exclusion when the member has an ongoing Residential Treatment Facility (RTF) claim covering more than 90 consecutive days as of the most recent eligibility update; the member must be discharged home from that RTF stay before becoming eligible again for Health Link.
Level of Care Criteria
Outpatient/Community-based care coordination
Includes individualized discharge planning and attention to domains listed in policy (medical/psychiatric, ADLs, education/vocation, social supports, etc.)
Treatment Modalities
Care coordination / health promotion — 1 top-level node
Providers encouraged to perform necessary additional activities to engage families and maintain treatment adherence
Recency & Coding Thresholds
Provider Actions & Authorization
Eligibility determination and authorization — document diagnosis and applicable eligibility category
Determine eligibility by documenting a diagnosable mental, behavioral, or emotional disorder that meets ICD‑10 or DSM‑V criteria (current or within the past year) and confirming the member meets one of the three THL eligibility categories: (1) specific diagnostic category, (2) utilization criteria combined with diagnosis, or (3) functional‑need pathway with recommendation from a treating licensed provider. Ensure consent for services is provided by the person with authority when applicable.
- Document diagnosis per ICD‑10 or DSM‑V (current or within past year).
- Confirm which THL eligibility category applies (diagnosis; utilization+diagnosis; or functional need with licensed provider recommendation).
- Obtain and document consent from the person authorized to consent to treatment.
Duplication/step restrictions — SOS, CTT, CCFT exclusions
Do not authorize continuation when the individual has been enrolled in SOS Level 1 or Level 2 for more than 30 consecutive days, or when the individual is authorized for CTT or CCFT services that duplicate THL activities.
- Verify SOS enrollment duration; >30 consecutive days precludes THL continuation.
- Confirm whether CTT or CCFT authorizations exist — duplication with THL activities disallows continuation.
Required clinical documentation — diagnosis, impairment, and evidence of benefit
Include clinical documentation that demonstrates a diagnosable disorder per ICD‑10/DSM‑V and evidence of functional impairment or another qualifying eligibility pathway; document care coordination plans, service notes, assessment tools, and outcomes measures to show progress and ongoing need or plan revisions.
- Diagnosis documentation meeting ICD‑10 or DSM‑V criteria (current or within past year).
- Evidence of functional impairment (impacting family, school, or community) or other qualifying pathway (utilization criteria or two behavioral conditions).
- Care Coordination plan, service notes, assessment tools, and outcomes-based measures demonstrating measurable progress or documented plan revisions and meaningful benefit.
RTF ongoing stay exclusion — >90 consecutive days disqualifies until discharged
Exclude individuals who have an ongoing residential treatment facility (RTF) stay that includes one or more RTF claims covering more than 90 consecutive days as of the most recent eligibility update; the individual must be discharged home from the RTF to regain eligibility.
- Confirm RTF claims: any ongoing RTF claim covering >90 consecutive days disqualifies for Health Link until discharged home.
Eligibility exclusion triggers — conditions that lead to denial
Screen for exclusion triggers that will lead to denial: absence of functional impairment or failure to meet diagnostic criteria, refusal of consent by the person authorized to consent, recent law‑enforcement or DCS involvement, multiple psychiatry‑driven ER presentations, recent medication instability, or other exclusion conditions outlined in the policy.
- Lack of functional impairment or failure to meet ICD‑10/DSM‑V diagnostic criteria.
- Refusal of Health Link services by the person with authority to consent.
- Involvement with law enforcement, juvenile justice, or Department of Children's Services within the last 6 months.
- At least two psychiatry‑driven ER presentations in the last 6 months.
- Medication adjustment in the previous 6 months due to instability with new conditions.
Definitions
Background
Tennessee Health Link is a team-based, whole-person care coordination model that integrates physical and behavioral health to meet the needs of children and adolescents with diagnosable mental, behavioral, or emotional disorders and accompanying functional impairment. The program uses comprehensive care management, outreach, care coordination, and health promotion/education to support recovery, maintain baseline functioning, and help prevent relapse to higher levels of acute care.
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