ModifiedNeighborhood Health Plan of Rhode IslandPolicy BH-002

Behavioral Health: Intermediate & Residential Services - # BH-002

Defines coverage, clinical eligibility, admission/continuation/discharge criteria, applicable lines of business, exclusions, and operational requirements for Intermediate and Residential behavioral health services (IHH/ACT, IOP, Enhanced Outpatient Services, Day/Evening Treatment, Opioid Treatment Program Health Home, and Mental Health Psychiatric Rehabilitative Residence) for Neighborhood Health Plan of Rhode Island members.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyBehavioral Health: Intermediate & Residential Services - # BH-002

Policy CodePolicy BH-002

Change TypeAdministrative update; clinical coverage statements present

Effective DateSep 1, 2025

Next Review Date

Key ActionProviders must use Neighborhood's prior authorization request forms on nhpri.org to request authorization; phone assistance available at 1-800-963-1001.

SourceLink

POLICY UPDATE CHANGES

Policy reviewed and updated with review and approval dates of 8/20/25 and effective date 9/1/25.

9Listed qualifying diagnoses for IHH/MHPRR

3Program types with specific admission criteria

90Days of inactivity leading to discharge (IHH)

6Months between required OTP plan reviews

Coverage Summary

Policy BH-002: Behavioral Health: Intermediate & Residential Services (effective 2025-09-01; last reviewed 08/20/2025) defines coverage for intermediate and residential behavioral health programs including IHH/ACT, IOP, EOS, Day/Evening Treatment, OTP Health Home, and MHPRR. The scope covers clinical eligibility, admission/continuation/discharge criteria, applicable lines of business, exclusions, and operational requirements for these programs and states the coverage stance as covered_with_criteria.

Key thresholds & quick facts

DLA threshold (IHH eligibility)DLA score of >3.0 - 5.0

IOP recommended intensityClinical services recommended ≥3 hours/day, 3 times/week

EOS continuation minimum face-to-faceMinimum of three (3) face-to-face clinical hours weekly

OTP plan review frequencyAssessment and individualized plan at initial engagement and at least every 6 months (or more often with significant change)

Days of inactivity leading to discharge (IHH)Member not participating in any service for 90 days despite documented engagement efforts

Medical-Necessity / Admission, Continuation, Discharge Criteria

Integrated Health Home (IHH) / Assertive Community Treatment (ACT) - Admission (Eligibility)

Covered when ALL of the following are met:

ALL of the following

ALL of the following
- ONE of
  - Bipolar Disorder
  - Borderline Personality Disorder
  - Delusional Disorder

Provider Actions & Operational Requirements

Prior Authorization

Prior authorization required

Providers must obtain prior authorization using Neighborhood's prior authorization request forms available on the Neighborhood website (Providers > Provider Resources > Forms > Authorization request forms). For assistance with requests or inquiries, including during and outside business hours, call Neighborhood's provider phone line at 1-800-963-1001.

Documentation Required

Treatment plan and licensed practitioner oversight

Requested services must be provided in accordance with a treatment plan approved by a licensed behavioral health practitioner (Physician, Licensed Psychologist, Registered Nurse, LMHC, LMFT, LCDP, or CISW). Mental Health Psychiatric Rehabilitative Residence (MHPRR) services specifically require physician authorization on the treatment plan and must be supervised by a registered nurse.

Coding and Lines of Business

Covered Codes - reference to Authorization Quick Reference GuidemixedCovered

Document refers providers to the Authorization Quick Reference Guide on Neighborhood's website for specific covered codes; no explicit CPT/HCPCS/ICD codes listed in policy text.

Excluded Lines of BusinessmixedNot Covered

EFP	Extended Family Planning - excluded from coverage

Providers: Specific CPT/HCPCS/ICD codes and coding guidance are referenced in Neighborhood's Authorization Quick Reference Guide available on nhpri.org; for Opioid Treatment Program (OTP) billing specifics, consult the EOHHS OTP Health Home Provider Billing Manual.

Background

Neighborhood's BH-002 policy establishes intermediate and residential behavioral health services for members with serious mental illness to provide recovery-oriented, person-centered, multidisciplinary care that integrates behavioral and physical health. The purpose is to ensure coordinated care (including care coordination, transitional care, and monitoring of chronic conditions), measure program performance, improve access to high-quality community-based services, and reduce overall costs.

Key definitions

Operational constraints & notes

Medicare Determinations

Medicare determinations: CMS guidance used for Integrity members (type: NCD); no effective date or specific NCD number is provided in the policy.

Revision History

2025-08-20reviewed/approvedLatest

Policy reviewed and updated; CMP Cross Reference and administrative metadata updated; clinical coverage statements present.

2025-09-01effectiveLatest

Policy reviewed and updated; CMP Cross Reference and administrative metadata updated; clinical coverage statements present.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyBehavioral Health: Intermediate & Residential Services - # BH-002

Policy CodePolicy BH-002

Change TypeAdministrative update; clinical coverage statements present

Effective DateSep 1, 2025

Next Review Date

Key ActionProviders must use Neighborhood's prior authorization request forms on nhpri.org to request authorization; phone assistance available at 1-800-963-1001.

SourceLink

On This Page

Major Depressive Disorder, Recurrent

Obsessive-Compulsive Disorder

Schizoaffective Disorder

Schizoid Personality Disorder

The State of Rhode Island Department of Behavioral Healthcare, Developmental Disabilities, and Hospitals (BHDDH) determines that the member is eligible for IHH

The member meets the highest level of care in use of the Daily Living Activities Functional Assessment (DLA): DLA score of >3.0 - 5.0DLA score of >3.0 - 5.0

NOTE: BHDDH may determine that the member qualifies for IHH when the member does not have a qualifying diagnosis but their DLA score indicates significant functional impairment

IHH/ACT - Discharge Criteria

Discharge appropriate when ONE of the following is met:

ANY of the following

Member has successfully reached their individually established goals for discharge and member and program staff mutually agree to termination of services
Member has demonstrated ability to function in all major role areas without ongoing assistance and without significant relapse when services are withdrawn and requests discharge with mutual agreement
Member has not participated in any service for a period of 90 days despite documented efforts to engage the member in treatment90 days

ref

Intensive Outpatient Treatment (IOP) - Admission Criteria

Admission appropriate when ALL of the following are met:

ALL of the following

Member has a current DSM or corresponding ICD-CM diagnosis
Member requires ongoing support to maintain their daily responsibilities in the community
There is an expectation for improvement with these services

ref

IOP - Minimum Program Requirements (operational)

Program should meet the following (recommended):

ALL of the following

Clinical services provided at least 3 hours per day, 3 times/week for BH and/or SUD (recommended)At least 3 hours per day, 3 times/week
recommended
Individualized treatment plan, assessment, medication evaluation, group, individual, family counseling, crisis intervention, activity therapies or psychoeducation as clinically appropriate
Licensed physician on staff or on call able to adjust/evaluate medication or designated program clinical staff coordinate/link to a prescriber
Licensed practitioner responsible to supervise program and staff and provide a treatment plan for each member

ref

Enhanced Outpatient Services (EOS) - Admission Coverage Criteria

Admission to EOS appropriate when ALL of the following are met:

ALL of the following

Member has a current DSM or corresponding ICD-CM diagnosis
Member is presenting with moderate to severe behavioral health symptoms and serious impairment is evident in multiple settings (family, social, school)
There is disruption in behavior or functional status and the Member requires more than office-based outpatient behavioral health treatment services
There is an expectation for improvement with these services
Member currently does not have any other therapeutic behavioral health home-based treatment service in place (other support services may continue with coordination)
Treatment will occur in a safe and stable home residence (excluding residential treatment facilities)
Parent or guardian agrees to work with the EOS provider and actively participate in the jointly developed treatment plan
At least ONE of the following
- Member discharged from a higher level of care in the past 30 days (e.g., inpatient, ARTS, PHP, IOP or day treatment)30 days
- Member had a recent admission (within 6 months) to a higher level of care6 months
- Member evaluated by licensed child clinician and determined to need diversionary service to avoid a more restrictive level of care
- An EOS intervention was successful prior to the current crisis (in the past 30 days) and EOS involvement is likely to stabilize the family30 days

ref

EOS - Continuation Coverage Criteria

Continuation appropriate when ALL of the following are met:

ALL of the following

Member continues to meet admission criteria and another LOC, either higher or lower, is not appropriate
A treatment plan has been updated addressing severity, current condition, and ongoing progress towards goals
Clinical services are provided at a minimum of three (3) face-to-face clinical hours weeklyMinimum of three (3) face-to-face clinical hours weekly
Member progress is reviewed at least weekly and treatment plan modified as needed
Medication assessment has been completed when appropriate; medication trials have been considered, started or ruled out
Parent or guardian continues to actively participate in, and are present for treatment as clinically required and appropriate; or engagement efforts are underway
Coordination of care and active discharge planning are occurring with goal of transitioning to a less intensive setting
Member continues to not have any other therapeutic behavioral health home-based treatment service in place (nontherapeutic support services may continue)

ref

EOS - Discharge Coverage Criteria

Discharge appropriate when ONE of the following are met:

ANY of the following

Member no longer meets admission criteria and another LOC is more appropriate
Member's individual treatment plan and goals have been met
Member has reached their optimal level of functioning based on limitations
Member, parent, or guardian withdraws consent for treatment
Member and parent/guardian do not appear to be actively participating in the treatment plan
Member is not making progress toward treatment goals and no expectation of progress
Member is clinically appropriate to attend routine outpatient treatment in an office or community-based setting

ref

Day/Evening Treatment - Admission Criteria

Admission appropriate when ALL of the following are met:

ALL of the following

Member has a current DSM or corresponding ICD-CM diagnosis
Member requires ongoing support to enhance current levels of functioning and skills to maintain community living
There is an expectation for improvement with these services

ref

Health Home Opioid Treatment Program (OTP) - Admission Criteria

Covered when ALL of the following are met:

ALL of the following

Active DSM-V diagnosis of opioid use disorder
Receiving or meet criteria for Medication Assisted Treatment (MOUD)
Have or be at risk for chronic physical illnesses
An assessment and individualized plan of care is completed at initial engagement and at least every 6 months or more frequently when significant change identifiedAt least every 6 months
Must be 18 years old or greaterMust be 18 years old or greater

ref

OTP - Enrollment Restrictions

Operational constraints:

ALL of the following

Members can only be enrolled in one specialized program at a time and cannot be simultaneously enrolled in IHH/ACT and OTP (duplication of services)
Services must comply with the EOHHS OTP HH Billing Manual

ref

Mental Health Psychiatric Rehabilitative Residence (MHPRR) - Admission Criteria

Covered when ALL of the following are met:

ref

Billing Rule

Service-specific billing manuals

Billing for services such as Integrated Health Home (IHH)/Assertive Community Treatment (ACT) and the Opioid Treatment Program (OTP) must comply with the applicable EOHHS program requirements and provider billing manuals. Follow the EOHHS Integrated Health Home description and the EOHHS IHH/ACT and OTP Health Home Provider Billing Manuals for billing compliance.

Denial Risk

Duplication of services denial risk

Claims may be denied for duplication when a member is enrolled in more than one specialized program at the same time. Examples of disallowed simultaneous enrollments include: IHH/ACT and OTP; IHH/ACT and CCBHC within the same month; ACT and MHPRR (members enrolled in ACT cannot also be involved in a MHPRR).