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    v1.0.30
    OpenPayerPolicy UpdatesPsychiatry/Behavioral HealthDHA Psychiatric PHP Coverage Update | OpenPayer
    Ask Trek AI about this page
    ModifiedDHAPolicy 6010.63-M

    Psychiatric and Substance Use Disorder Partial Hospitalization Programs

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    This policy governs psychiatric and substance use disorder partial hospitalization programs under the DHA TRICARE policy manual.

    Policy Summary
    PayerDHA
    PolicyPsychiatric and Substance Use Disorder Partial Hospitalization Programs
    Policy CodePolicy 6010.63-M
    Change TypeModified
    Effective DateOctober 3, 2016
    Next Review DateN/A
    Key ActionObtain a PCM referral for PHP services, unless the contractor accepts a network PHP provider’s preauthorization request instead.
    SourceLink
    POLICY UPDATE CHANGES

    Quantitative limits on mental health and substance use disorder care were removed effective October 3, 2016.

    All criteria requiredMedical necessity standard
    PCM referralPHP referral
    NoneCare limits
    All-inclusive per diemReimbursement structure

    Coverage Criteria

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    Diagnostic and functional requirements

    Mental health or SUD benefits require all of the following diagnostic and functional conditions.

    Qualifying diagnosis and impairment: The patient must be diagnosed by a licensed, qualified mental health professional with a mental disorder under the current DSM or the applicable ICD-9-CM or ICD-10-CM diagnostic framework, and must experience both physical or psychological distress and impairment in occupational, educational, or social functioning as a result of the diagnosed disorder.

    Certain mental disorders may have limited benefits.

    PHP medical necessity

    PHP services are necessary only when all of the following conditions are present.

    • Significant impairment or withdrawal-management need

      • Mental disorder or SUD impairment: The patient has significant impairment from a mental disorder, including SUD, that interferes with age-appropriate functioning.
      • Withdrawal-management need: The patient needs rehabilitative services for management of withdrawal symptoms from alcohol, sedative-hypnotics, opioids, or stimulants requiring medically monitored ambulatory detoxification, direct access to medical services, and clinically intensive rehabilitative care based on an individualized treatment plan.
    • Community and safety status: The patient cannot maintain an adequate course of therapy exclusively on an outpatient basis with appropriate community support, but can maintain a basic level of functioning sufficient for PHP with appropriate support and has no substantial imminent risk of harm to self or others.

    • Indication for PHP level of care

      • Crisis stabilization: The patient needs crisis stabilization.
      • Partially stabilized disorder treatment: The patient needs treatment of a partially stabilized mental health disorder or SUD.
      • Transition from inpatient care: The patient needs services as a transition from an inpatient program.
    • Individualized treatment plan: Admission is based on an individualized diagnosis and treatment plan expected to be effective for the patient and permit treatment at a less intensive level.

    No benefits are payable for conditions not attributable to a mental disorder, including conditions reported with ICD-9-CM V codes or ICD-10-CM Z codes.

    PHP is not medically necessary when the patient can maintain an adequate course of therapy exclusively on an outpatient basis with appropriate support, cannot maintain the basic level of functioning needed to participate in PHP, or presents a substantial imminent risk of harm to self or others.

    Provider Requirements and Denial Risks

    Prior Authorization

    Referral or Accepted Network-Provider Request

    A Primary Care Manager (PCM) referral is required for PHP services. Preauthorization is not required for admission; however, when the PHP is provided by a network provider, the contractor may accept a preauthorization request submitted by that network PHP provider in lieu of the PCM referral.

    • Action: Obtain and retain the PCM referral, or document the accepted preauthorization request from the network PHP provider.
    • Preauthorization is not otherwise required for PHP admission.
    Documentation Required

    Clinical Necessity Documentation

    Document the diagnosis, qualified-professional evaluation, functional impairment, and individualized clinical rationale supporting medically or psychologically necessary PHP treatment. The record must show that the patient meets all applicable PHP medical-necessity conditions and has an individualized diagnosis and treatment plan expected to support treatment at a less intensive level.

    • The patient must be diagnosed by a licensed, qualified mental health professional with a mental disorder, including SUD, under applicable DSM or ICD-10-CM criteria.
    • Document significant impairment in age-appropriate occupational, educational, or social functioning, or the need for medically monitored ambulatory detoxification with direct medical access and clinically intensive rehabilitative programming.
    • Document why outpatient treatment alone is insufficient, while the patient remains able to maintain a basic level of functioning for PHP and presents no substantial imminent risk of harm to self or others.
    • Document the clinical purpose: crisis stabilization, treatment of a partially stabilized mental health or SUD condition, or transition from inpatient care.
    Documentation Required

    Program Authorization Documentation

    Before providing authorized PHP services, verify and document that the program has entered into the required participation agreement and provides a multidisciplinary program. The program must also be accredited and in substantial compliance with an accepted accrediting organization or approved by DHA.

    • Retain evidence of the PHP participation agreement under the applicable TRICARE requirements.
    • Document the multidisciplinary program and its all-inclusive per diem arrangement.
    • Acceptable accreditation includes TJC, CARF, CoA, or an accrediting organization approved by DHA; additional organizations may be submitted for TRICARE authorization subject to Government Designated Authority approval.
    Denial Risk

    No Qualifying Diagnosis or Medical Necessity

    PHP benefits are not payable when the patient lacks a qualifying mental-disorder or SUD diagnosis, or when the record does not establish medical or psychological necessity. Conditions not attributable to a mental disorder, ICD-9-CM V codes, and ICD-10-CM Z codes do not qualify for benefits.

    • The diagnosis must be made by a licensed, qualified mental health professional under the applicable diagnostic criteria.
    • Document both distress and impaired occupational, educational, or social functioning when treating a diagnosed mental disorder.
    • Deny or do not bill PHP when the required diagnosis, functional impairment, or clinical necessity documentation is absent.
    Denial Risk

    Wrong Level of Care or Unsafe Placement

    PHP is not appropriate when the patient can receive an adequate course of therapy exclusively on an outpatient basis, cannot maintain the basic level of functioning needed for PHP, or presents a substantial imminent risk of harm to self or others. The level of care must match the patient’s functional impairment and clinical needs.

    • Do not use PHP when outpatient care is sufficient.
    • Do not place a patient in PHP who is unable to maintain basic functioning in the PHP setting or who requires a more intensive level of care.
    • Do not admit when there is substantial imminent risk of harm to self or others; evaluate for a safer or more intensive placement.
    Denial Risk

    Unauthorized or Unaccredited PHP

    Only an authorized PHP may provide covered services. The program must have a participation agreement, provide a multidisciplinary program, and be accredited and in substantial compliance with TJC, CARF, CoA, or another accrediting organization approved by DHA.

    • Verify the participation agreement before admission or billing.
    • Verify current accreditation or DHA approval and substantial compliance.
    • Services from an unauthorized or unaccredited PHP are subject to denial.
    Denial Risk

    Missing Required Referral

    A PCM referral is required for PHP services unless the PHP is a network provider and the contractor accepts the network provider’s preauthorization request in lieu of the referral. Because preauthorization is otherwise not required for PHP admission, the permitted network-provider exception must be specifically documented.

    • Missing PCM referral without the permitted network PHP-provider exception is a denial risk.
    • Retain the accepted preauthorization request when it is used instead of a PCM referral.
    • Do not treat a non-network provider’s preauthorization request as a substitute for the required PCM referral.

    Program Overview

    Psychiatric and SUD partial hospitalization is a time-limited, ambulatory, active treatment setting that provides therapeutically intensive, coordinated, and structured clinical services in a stable therapeutic environment. It may support crisis stabilization, treatment of a partially stabilized mental health disorder or SUD, medically monitored ambulatory withdrawal management, or transition from an inpatient program when medically or psychologically necessary to prevent serious deterioration in functioning.

    Covered Service Definitions

    Psychiatric and SUD partial hospitalization
    Program typeTime-limited, ambulatory, active treatment program
    ServicesInterdisciplinary medical and therapeutic services, including withdrawal-symptom management when medically indicated
    Program structureIntegrated and structured schedule of recognized treatment approaches, with therapeutically intensive, coordinated, and structured clinical services in a stable therapeutic environment
    Treatment schedulesMay operate during day, evening, night, or weekend hours
    Appropriate usesCrisis stabilization, treatment of partially stabilized mental disorders including substance use disorders, and transition from an inpatient program when medically necessary
    Medically monitored ambulatory detoxification
    Treatment purposeRehabilitative treatment for withdrawal from alcohol, sedative-hypnotics, opioids, or stimulants
    Medical oversightRequires medically monitored ambulatory detoxification with direct access to medical services
    Program intensityClinically intensive rehabilitative programming
    Treatment planningCare is based on an individual treatment plan
    Applicable settingAmbulatory partial hospitalization services

    PHP Level-of-Care Framework

    Policy Summary
    PayerDHA
    PolicyPsychiatric and Substance Use Disorder Partial Hospitalization Programs
    Policy CodePolicy 6010.63-M
    Change TypeModified
    Effective DateOctober 3, 2016
    Next Review DateN/A
    Key ActionObtain a PCM referral for PHP services, unless the contractor accepts a network PHP provider’s preauthorization request instead.
    SourceLink
    On This Page
    Coverage CriteriaProvider Requirements and Denial RisksProgram OverviewCovered Service DefinitionsPHP Level-of-Care Framework