CurrentCareSource GeorgiaPolicy MP-PY1480
Partial Hospitalization Program - Behavioral Health
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Defines CareSource Georgia's reimbursement, billing, prior authorization, medical necessity, and coverage rules for Partial Hospitalization Programs (behavioral health and SUD) for Marketplace products; applies to listed Marketplace states and providers contracting with CareSource.
Policy Summary
PayerCareSource Georgia
PolicyPartial Hospitalization Program - Behavioral Health
Policy CodePolicy MP-PY1480
Change TypeNo material change
Effective DateSep 1, 2024
Last ReviewSep 1, 2024
Next Review Date
Key ActionObtain prior authorization after the first 5 calendar days of Partial Hospitalization; CareSource uses MCG for mental health and ASAM for SUD reviews.
SourceLink
POLICY UPDATE CHANGES
No material clinical or coverage changes in this revision.
20 hoursPhysician-cert hours/week
5 daysDays before PA required
GA, IN, KY, OH, WVCovered Marketplaces
cond code 41Claims identifier
Coverage & Medical Necessity Criteria
PHP coverage and medical necessity criteria
Covered when ALL of the following are met:
Member has a DSM diagnosis causing severe interference with multiple areas of functioning (social, vocational, educational) generally of an acute nature; the condition requires a comprehensive, structured, multimodal treatment program with medical supervision and coordination.
A physician certifies the member requires a minimum of 20 hours per week of therapeutic services provided by the PHP.
Member is able to participate cognitively and emotionally in active treatment and can tolerate the intensity of PHP services.
PHP is being used either as a step-down following inpatient hospitalization or for a member at reasonable risk of inpatient admission; when used to shorten an inpatient stay, documentation must demonstrate the need for PHP services.
Level-of-Care: Partial Hospitalization Program (PHP)
Partial Hospitalization (PHP)
Admission, continued stay, and utilization management rules for Partial Hospitalization Program (PHP):
ALL of the following
- Diagnosis from the Diagnostic and Statistical Manual of Mental Disorders causing severe interference with multiple areas of daily life (social, vocational, educational).
- Requires comprehensive, structured, multimodal treatment with medical supervision and coordination.
- Physician certification of a minimum of 20 hours per week of therapeutic services.
- Member able to participate cognitively and emotionally and tolerate the intensity of PHP.
ALL of the following
- Recertification must document the continuing serious nature of the psychiatric condition requiring ongoing active treatment.
- When PHP is used to shorten an inpatient stay, recertification must include evidence supporting need for ongoing PHP services.
ALL of the following
- Prior authorization is required beginning after 5 days of PHP services per calendar year.
- CareSource uses MCG criteria for mental health medical necessity reviews and ASAM criteria for substance use disorder reviews.
- State-specific rule (West Virginia): first 5 days provided without retrospective review; benefits beginning day 6 and every 6 days thereafter are subject to concurrent review.
ALL of the following
- ONE of: Day care programs that are primarily social, recreational, or diversionary, custodial or respite care.
- ONE of: Programs that maintain psychiatric wellness where there is no risk of relapse or hospitalization.
- ONE of: Services for members who are psychiatrically stable or require medication management only.
- ONE of: Services to inpatient members at a hospital that are non-covered (meals, self-administration of medication, transportation, vocational training).
- ONE of: Members who cannot or refuse to participate in treatment (e.g., low cognitive status, volatile behavior) or cannot tolerate PHP intensity.
- ONE of: Treatment of chronic conditions without an acute exacerbation that places the member at risk of relapse or hospitalization.
ALL of the following
- Discharge planning must include linkages to community resources, supports, and providers to promote return to higher functioning in the least restrictive environment.
ALL of the following
- Providers must follow billing, coding, and documentation guidelines; reporting of service units, patient status, and discharge status is required.
- PHP services must be identified on claims per policy instructions; provider agreements govern if in conflict with this policy.
Multidisciplinary Services & Treatment Modalities
PHP multidisciplinary services
PHP must deliver multidisciplinary services as part of the individualized treatment plan; services may include, but are not limited to:
Individual and group psychotherapy provided by physicians, psychologists, or other authorized mental health professionals.
Occupational therapy delivered by a qualified occupational therapist when clinically indicated.
Services of social workers, trained psychiatric nurses, and other staff trained to work with psychiatric and SUD populations.
Drugs and biologicals furnished for therapeutic purposes that cannot be self-administered per regulations.
Individualized activity therapies that are therapeutic in purpose and not primarily recreational or diversionary.
Family counseling focused on treatment of the individual's diagnosis, including caregiver counseling when indicated.
Patient training and education closely related to the individual's care and treatment, and diagnostic services as needed.
Claim Identifiers, Billing Structure, and APC Grouping
PHP claim identifiers and billing structuremixed
| condition code 41 | Identifier for PHP services on claims |
| TOB 13X | Type of Bill - outpatient hospital |
| TOB 85X | Type of Bill - critical access hospital (CAH) |
| TOB 76X | Type of Bill - community mental health center (CMHC) |
| days with 3 or fewer services | APC grouping: days with 3 or fewer services a day |
| days with 4 or more services | APC grouping: days with 4 or more services a day |
Service-per-day thresholds for APC grouping
APC grouping thresholdsPHP APCs are reported separately for days with 3 or fewer services per day vs days with 4 or more services per day.
Type of bill guidanceUse appropriate Type of Bills for institutional billing: TOB 13X (outpatient hospital), TOB 85X (critical access hospital), TOB 76X (community mental health center).
Sequence and consistencyClaims for a continuing course of treatment must be submitted in sequence; consistency editing enforced for interim PHP billing.
Service unit reportingProviders must report service units for billed codes and include patient status and discharge status codes as required.
Prior Authorization, Review, and Provider Requirements
Prior Authorization
Prior authorization required after 5 PHP days; MCG/ASAM review criteria
Prior authorization is required once a member has received more than five days of Partial Hospitalization Program (PHP) services in a calendar year. CareSource uses MCG criteria for medical necessity reviews of mental health PHP requests and ASAM criteria for substance use disorder reviews. (West Virginia: first 5 days provided without retrospective review; benefits beginning day 6 and every 6 days thereafter are subject to concurrent review.)
- Prior authorization required after 5 days per calendar year.
- CareSource follows MCG criteria for mental health reviews and ASAM criteria for SUD reviews.
- West Virginia exception: days 1–5 covered without retrospective review; day 6 and every 6 days thereafter subject to concurrent review.
Documentation Required
Definitions: Concurrent Review and Retrospective Review
Concurrent Review is defined as a request for prior authorization or a predetermination submitted before or during the course of receiving a health care service; Retrospective Review is a request for medical review submitted after the service has been received.
- Concurrent Review: request for prior authorization or predetermination submitted before or during care.
- Retrospective Review: request for medical review submitted after the service has been received.
Key Definitions
Partial Hospitalization
DefinitionPartial Hospitalization: structured, multimodal, active treatment for behavioral health needs with treatment periods less than 24 hours, including individual/group/family psychotherapy, education, and diagnostics.
Physician certificationA physician must certify the member's need for a minimum of 20 hours per week of therapeutic services for PHP eligibility.
Appropriate use casesTypically for members discharged from inpatient care as a step-down or for those at reasonable risk of requiring inpatient hospitalization; evidence required when PHP shortens an inpatient stay.
Exclusions / not medically necessaryDay care programs that are primarily social, custodial/respite care, services for psychiatrically stable members or medication management only, inpatient services items (meals, self-administration of meds, transportation), members unable/refusing to participate, and treatment of chronic conditions without acute exacerbation.
Intensive Outpatient Program (IOP)
DefinitionIntensive Outpatient Program (IOP): services addressing behavioral health needs provided at least 3 hours/day, 2–3 days/week, usually a step down from inpatient, PHP, or residential care and a step up from traditional outpatient services.
Relation to PHPIOP is typically less intensive than PHP and used as a step-down level of care when clinically appropriate.
Service settingProvided by facilities, group practices, or clinics.
Concurrent Review
DefinitionConcurrent Review: a request for prior authorization or a predetermination submitted before or during the course of receiving a health care service.
TimingSubmitted prior to or during the course of treatment (not after).
PurposeUsed to review medical necessity while services are ongoing to determine continued coverage or need for modification of level of care.
Retrospective Review
DefinitionRetrospective Review: a request for medical review that is submitted after the health care service has been received.
Use caseApplied when review of medical necessity or coverage determination is requested subsequent to service delivery.
State exception (WV)West Virginia: benefits for the first 5 days provided without retrospective review; day 6 onward are subject to concurrent review every 6 days.
Physician certification
RequirementA physician must certify a member's need for a minimum of 20 hours per week of therapeutic services for PHP.
Clinical basisCertification is for members requiring comprehensive, structured, multimodal treatment with medical supervision due to a DSM diagnosis that severely interferes with multiple areas of functioning.
Member capabilityMember must be able to participate cognitively and emotionally and tolerate PHP intensity.
Visit Limits & Calendar-Year Requirements
Partial Hospitalization Program - Visit limits and review
Initial visit limit before authorizationPrior authorization is required after 5 days per calendar year (first 5 days do not require prior authorization).
West Virginia special ruleWest Virginia: benefits for the first 5 days provided without retrospective review; benefits beginning day 6 and every 6 days thereafter are subject to concurrent review of medical necessity.
RecertificationRecertification must document the continuing, serious nature of the psychiatric condition requiring ongoing active treatment.
Policy Summary
PayerCareSource Georgia
PolicyPartial Hospitalization Program - Behavioral Health
Policy CodePolicy MP-PY1480
Change TypeNo material change
Effective DateSep 1, 2024
Last ReviewSep 1, 2024
Next Review Date
Key ActionObtain prior authorization after the first 5 calendar days of Partial Hospitalization; CareSource uses MCG for mental health and ASAM for SUD reviews.
SourceLink
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