CurrentNeighborhood Health Plan of Rhode IslandPolicy 028

Hasbro Partial Program (Pediatric Partial Hospitalization)

Defines admission, continued stay, and discharge criteria for the Hasbro Partial Program — a pediatric partial hospital/partial program for children with concurrent medical and behavioral health needs — and describes authorization and prior authorization processes for Neighborhood Health Plan of Rhode Island members. Affects providers requesting authorization for this program (excludes certain products listed).

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyHasbro Partial Program (Pediatric Partial Hospitalization)

Policy CodePolicy 028

Change TypeNo material change

Effective Date2014-01-28 and subsequent effective dates listed

Next Review Date

Key ActionObtain prior authorization using the Authorization Request Forms on the provider website or call 1-800-963-1001 and submit medical necessity documentation to Utilization Management.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

AprCMP annual review month

028Policy identifier

2025-04-09Most recent review

MultipleProducts excluded

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inv-01: Admission Criteria

Covered when ALL of the following are met (Criteria 1-4 required; criterion 5 recommended):

Required admission criteria: 1) The child has active medical and active behavioral health diagnoses that are treatable in a hospital partial setting; 2) The child has a psychiatric or behavioral condition placing them at risk for deterioration in status and/or at potential risk for inpatient facility admission; 3) The medical condition is unstable and cannot be managed in the home environment due to psychosocial or environmental barriers; 4) The child and parent/guardian have the capacity for reliable attendance and active participation in all phases of the treatment.

Criterion #5 is recommended but not required per policy.

inv-02: Continued Stay Criteria

Authorization for continued stay must meet the following:

Continued stay requirements: 1) The child continues to meet the admission criteria and less intensive care is not appropriate; 2) The plan and progress are monitored with documentation demonstrating progress toward goals; 3) The member and/or family demonstrate compliance with the treatment plan; 4) Active discharge planning is ongoing with documentation demonstrating transition to a less intensive level of care as the goal.

The Hasbro Partial Program is excluded from coverage for certain Neighborhood products. Specifically, this program is not covered for members enrolled in the Health Benefits Exchange (HBE), Rite Care (MED), Children with Special Needs (CSN), Substitute Care (SUB), Rhody Health Partners (RHP), Rhody Health Expansion (RHE), the Medicare Advantage product (distinct guidance applies), and Extended Family Planning (EFP).

Partial Hospitalization / Partial Program (Pediatric) Criteria

inv-11: Partial Hospitalization / Partial Program (pediatric)

Criteria for Partial Hospitalization / Partial Program (pediatric): admission and continued-stay medical necessity requirements for this level of care.

Partial Hospitalization / Partial Program (pediatric) — combined criteria

Admission criteria (see above): 1) Active medical and behavioral diagnoses treatable in a hospital partial setting; 2) Psychiatric/behavioral condition placing the child at risk for deterioration or inpatient admission; 3) Medical condition unstable and not manageable at home due to psychosocial/environmental barriers; 4) Child and parent/guardian capable of reliable attendance and active participation.
Criterion #5 is recommended.
Continued stay criteria (see above): 1) Continued meeting of admission criteria with less intensive care inappropriate; 2) Documented monitoring of plan and progress with evidence of progress toward goals; 3) Member/family compliance with treatment plan; 4) Active discharge planning with documented transition goals to less intensive care.

Authorization, Documentation, and Provider Responsibilities

Prior Authorization

Prior authorization required — use Authorization Request Forms

Prior authorization is required for admission to the Hasbro Partial Program. Submit an Authorization Request using the Authorization Request Forms available under Provider Resources → Forms on the Neighborhood website; assistance is available by phone at 1-800-963-1001.

Step Therapy

Maximize or fail less intensive settings before admission

Other appropriate treatment settings must have been maximized, failed, or be unavailable before admitting a child to the partial program (examples include acute hospital, home environment, or group home).

Examples listed in policy: acute hospital, home environment, group home

Documentation Required

Submit medical necessity documentation for unstable medical co-morbid conditions

When a child's medical co-morbid conditions are unstable, providers must send medical necessity documentation to Neighborhood Utilization Management to request authorization; continued stay requests must include documentation showing continued meeting of admission criteria, progress toward goals, compliance, and active discharge planning.

Submit documentation to Neighborhood Utilization Management when medical co-morbid conditions are unstable
Continued stay: document continued admission criteria, monitored progress toward goals, member/family compliance, and active discharge planning

Denial Risk

Prior authorization and medical review required — risk of denial if not provided

Prior authorization and medical review are required for this program; lack of prior authorization or insufficient medical necessity documentation may lead to denial of coverage.

Program Definition and Scope

Program definition — Hasbro Partial Program

Program nameHasbro Partial Program (pediatric partial hospital/partial program)

PopulationChildren with concurrent medical and psychiatric/behavioral health conditions requiring interdisciplinary team management

Clinical circumstance for useWhen the child has active medical and active behavioral health diagnoses treatable in a hospital partial setting and medical co-morbid conditions are unstable

Care teamInterdisciplinary team to manage both medical and behavioral health needs

Authorization requirementProviders must submit medical necessity documentation to Neighborhood Utilization Management to request authorization when medical co-morbid conditions are unstable

Background and Program Description

The Hasbro Partial Program is a pediatric partial hospitalization/partial program designed for children who have concurrent active medical and behavioral health diagnoses that require coordinated interdisciplinary team management. The program is intended for children whose psychiatric or behavioral condition places them at risk for clinical deterioration or possible inpatient admission, and whose medical condition is unstable and cannot be managed safely at home due to psychosocial or environmental barriers.

Admission to the program requires that the child and their parent/guardian demonstrate the capacity for reliable attendance and active participation in treatment. The service model emphasizes integrated medical and behavioral interventions delivered in a partial hospital setting to address both medical instability and behavioral health risk while working toward stabilization and transition to a less intensive level of care when appropriate.