Centene PRTF Level I II Coverage Update

Coverage and Medical Necessity Criteria

inv-01: Level I Admission

Level I PRTF services are covered when ALL of the following are met:

Level I admission criteria: Enrollee is age 6 through 20 years (may continue based on medical necessity if receiving active treatment on 21st birthday until not yet 22); Medicaid payment status criteria is met; requires long-term inpatient psychiatric care or crisis stabilization more suitably provided in a PRTF than a psychiatric hospital; requires continuous Level I services due to severe mental or psychiatric illness including severe emotional disturbance.

See determining patient status for regulatory criteria.

inv-02: Level II Admission

Level II PRTF services are covered when ALL of the following are met:

Level II admission criteria: Prior authorization has been secured; enrollee is age 4 through 21 years (coverage may continue if receiving active treatment on 21st birthday until not yet 22); meets Medicaid payment status criteria; has a severe emotional disability plus at least one of: severe and persistent aggressive behaviors, an intellectual disability, sexually acting out behaviors, or a developmental disability; does not meet medical necessity criteria for an acute care hospital, private psychiatric hospital, or state mental hospital; treatment needs cannot be met in an ambulatory care setting, Level I PRTF, or any other less restrictive environment.

Prior authorization required; see state-specific continuation rules.

inv-03: Not Medically Necessary Services

Services considered not medically necessary (explicit list):

Service types NMN: Outpatient services; Pharmacy services; Durable medical equipment; Hospital emergency room services; Acute care hospital inpatient services; Laboratory and radiology services; Dental services; Hearing and vision services; Ambulance services; Chemical dependency treatment services when the need for such services is the enrollee's primary diagnosis; Level I or II PRTF services when appropriate alternative services are available in the community.

Chemical dependency treatment may be covered incidentally if minimal and necessary to treat the primary diagnosis.

inv-04: Patient Status Not Covered

Patient condition exclusions (NMN):

Patient exclusions: Individuals with a major medical problem; individuals with only minor symptoms; individuals who might only require a psychiatric consultation rather than PRTF admission; individuals who only need adequate living accommodations, economic aid, or social support services.

PRTF services exclude care when the primary diagnosis is chemical dependency; chemical dependency treatment may only be provided incidentally if minimal and necessary to treat the enrollee's primary diagnosis. Additionally, individuals whose needs are driven by a major medical problem, who present with only minor symptoms, who only require a psychiatric consultation rather than admission, or who only require adequate living accommodations, economic aid, or social support services are not appropriate for PRTF admission.

When Kentucky Medicaid coverage provisions or other state plan requirements differ from this clinical policy, the applicable state Medicaid manual and state plan provisions take precedence over the policy. Coverage decisions remain subject to all terms, conditions, exclusions and limitations of the enrollee's coverage documents and to applicable state and federal requirements.

The following services are explicitly excluded from PRTF coverage: outpatient services; pharmacy services; durable medical equipment (DME); hospital emergency room services; acute care hospital inpatient services; laboratory and radiology services; dental services; hearing and vision services; ambulance services; and chemical dependency treatment when the enrollee's primary diagnosis is substance use disorder. Note that treatment plans must still include appropriate diagnostic, therapeutic, psychiatric, nursing, medication, educational and crisis-intervention services as described elsewhere in the policy.

Billing Codes and Review Frequency

CPT Codes referencedCPT

90785	Psytx complex interactive.
90791	Psych diagnostic evaluation.
90792	Psych diag eval w/med srvcs.
90832	Psytx w pt 30 minutes.
90833	Psytx w pt w e/m 30 min.
90834	Psytx w pt 45 minutes.
90836	Psytx w pt w e/m 45 min.
90837	Psytx w pt 60 minutes.
90838	Psytx w pt w e/m 60 min.
90839	Psytx crisis initial 60 min.

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Additional CPT and revenue/classification codesmixed

96110	Developmental screen w/score
012x	Hospital inpatient (part B only)
013x	Hospital Outpatient
071x	Clinic-rural health
075x	Clinic comprehensive outpatient rehab facility (CORF)
076x	Clinic-community mental health center
085x	Critical access hospital
0900	Behavioral Health Treatment/Services - General Classification
0901	Behavioral Health Treatment/Services - Electroshock Treatment
0914	Behavioral Health Treatment/Services - Individual Therapy

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Re-evaluation / continued review frequency — Level I and Level II

Level I re-evaluation frequencyRe-evaluate at least once every 30 days; treatment plan reviewed at least once every 3 days (signatures dated).

Level II initial reviewInitial review completed by no later than the third business day following admission.

Level II continued review (ages 4-5)After the initial review, re-evaluate at least every 14 days.

Level II continued review (ages 6-22)After the initial review, re-evaluate at least every 30 days.

Documentation required at reviewsAll reviews must include discharge planning, dated signatures of appropriate staff and parent/guardian, assessment of progress toward each treatment plan goal with revisions indicated, and justification for continued level of services and suitability for less-restrictive environment.

Prior Authorization, Documentation, and Provider Responsibilities

Prior Authorization

Prior Authorization Required

Prior authorization is required for Level II PRTF services. Providers must secure prior authorization before admission for Level II care.

Prior authorization required for Level II PRTF services.

Note

State-Regulated PRTF Prior Authorization

Kentucky state plan and regulatory requirements apply to PRTF services for individuals under 21. Providers must follow 907 KAR 9:005 and the Kentucky Medicaid State Plan Attachment 3.1-A provisions when requesting prior authorization and documenting medical necessity.

907 KAR 9:005 (Non-outpatient Level I and II PRTF service and coverage policies).
Kentucky State Plan Attachment 3.1-A — PRTF services for individuals under 21.

Residential Level of Care Definitions and Regulatory References

inv-25: Residential (PRTF Level I and Level II)

Core residential criteria and continued-stay requirements for PRTF Level I and Level II:

Residential (PRTF Level I and Level II) core criteria: Admission and continued stay must meet the applicable Level I or Level II patient status definitions (see Level I and Level II admission criteria); treatment needs cannot be met in less restrictive settings; Level II requires physician-directed services and prior authorization; age and Medicaid payment status requirements must be met; coverage may continue to age 22 if active treatment is ongoing on the 21st birthday.

Continued stay reviews: Level I re-evaluation at least every 30 days; Level II initial review by third business day, then for ages 4–5 every 14 days and for ages 6–22 every 30 days.

inv-26: PRTF Level I and II referenced regulatory sources

Regulatory and policy sources referenced for Level I and Level II PRTF services:

Regulatory references: Kentucky administrative regulation 907 KAR 9:005; Kentucky State Plan Attachment 3.1-A for PRTF services; CMS local coverage determination L34353 for outpatient psychiatry and psychology services (as applicable).

Required Therapeutic Services and Modalities

inv-27: Psychotherapy, medication management, crisis intervention, educational and support services

Therapies, medication management, crisis intervention, educational and support services provided in PRTF:

Therapies and services: Diagnostic and assessment services; treatment plan development, review, or revision; psychiatric services; nursing services; medication management; evidence-based treatment interventions; individual therapy; family therapy or attempted contact with family; group therapy; substance abuse education; individual and group interventions addressing harmful use or relapse prevention as indicated; crisis intervention; consultation with other professionals (case managers, primary care, community support, school staff); educational activities; non-medical transportation as needed; discharge planning beginning at admission.

Level II services must be provided under physician direction; most therapeutic services at least once weekly or twice weekly if indicated; diagnostic/assessment services have no weekly minimum.

Therapeutic Service Frequency and Visit Minimums

Therapeutic services listed for PRTF — weekly frequency

Therapeutic services weekly minimumTherapeutic services must be provided at least once per week; if clinically necessary, services shall be provided at least twice per week.

Diagnostic/assessment servicesDiagnostic and assessment services have no weekly minimum requirement.

ApplicabilityFrequency requirement applies to services included in the enrollee's initial and current treatment plan and must be clinically warranted.

Definitions and Level Descriptions

Level I PRTF care — definition and characteristics

DefinitionCare for recipients requiring long‑term inpatient psychiatric care or crisis stabilization more suitably provided in a PRTF than in a psychiatric hospital, requiring continuous Level I services due to severe mental or psychiatric illness including severe emotional disturbance.

Age rangePrimarily for enrollees age 6 through 20 (may continue to age 21 if receiving active treatment and not yet 22).

Key characteristicsContinuous Level I services, treatment in a less‑restrictive setting must be assessed; discharge planning begins at admission.

Level II PRTF care — definition and characteristics

DefinitionCare for children with a severe emotional disability who require long‑term inpatient psychiatric care or crisis stabilization more suitably provided in a PRTF than a psychiatric hospital and who have an additional condition such as severe/persistent aggressive behaviors, intellectual disability, sexually acting out behaviors, or a developmental disability.

Background and Scope

Psychiatric Residential Treatment Facility (PRTF) services provide long‑term, intensive, structured inpatient behavioral health treatment for children and young adults who require more than family- or community-based alternatives. Level I PRTF serves enrollees generally aged 6 through 20 (with limited continuation to age 21/22 when actively receiving treatment) who require continuous inpatient psychiatric care or crisis stabilization better suited to a PRTF than a psychiatric hospital. Level II PRTF serves enrollees generally aged 4 through 21 who have a severe emotional disability plus qualifying conditions (for example, severe/persistent aggressive behavior, intellectual or developmental disability, or sexually acting‑out behaviors) and whose treatment needs cannot be met in ambulatory care, Level I PRTF, or any less restrictive environment.

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Psychiatric Residential Treatment Facilities (PRTF Level I and II)