Neighborhood Health Plan RI behavioral health Coverage

Coverage Criteria and Admission/Continuation Rules

Clubhouse — Initial Coverage Criteria

Clubhouse covered when ALL of the following are met

Clubhouse initial eligibility: Member has a diagnosis of one of: Bipolar Disorder; Borderline Personality Disorder; Delusion Disorder; Major Depressive Disorder, Recurrent; Obsessive-Compulsive Disorder; Psychotic Disorder; Schizoaffective Disorder; Schizoid Personality Disorder; Schizophrenia.

from Coverage Determination

Assessment and planning: Provider has collected information on the member's vocational, educational, social relationships, and independent living goals and a current psychiatric evaluation.

provider assessment requirements

Activity plan timing and signatures: Provider and member must develop an activity plan no later than 1 week after the member began Clubhouse; records must be signed by the provider and the member.1 week

activity plan timing and signatures required

Activity plan content and documentation: Activity plan must include member goals; skills/knowledge/activities or other interventions for each goal; activities to improve engagement; plan to coordinate Clubhouse services with the member's behavioral health and other providers; documentation includes at least weekly progress notes that address each service provided.weekly notes

activity plan content and weekly documentation

Service intensity: Clubhouse services should include a minimum of three (3) hours per service, at least one time per week.>=3 hours once weekly

service minimum

Supported Employment — Coverage Criteria

Supported Employment covered when ALL of the following are met

Supported Employment diagnosis: Member has a diagnosis of one of: Bipolar Disorder; Borderline Personality Disorder; Delusion Disorder; Major Depressive Disorder, Recurrent; Obsessive-Compulsive Disorder; Psychotic Disorder; Schizoaffective Disorder; Schizoid Personality Disorder; Schizophrenia.

same diagnostic list as Clubhouse

Prior attempts and functional need: Member has been unsuccessful with traditional employment strategies and requires ongoing supports to choose, find, and keep employment.

functional need documented

Plan review: Provider and member must conduct a formal review of the plan at least every 6 months or more often if significant changes occur; involve the employer as appropriate.>=every 6 months

ongoing documentation requirement

Community Based Narcotic Treatment — Admission Criteria

Community Based Narcotic Treatment (Opioid Treatment Services) covered when ALL of the following are met

Opioid use disorder diagnosis: Have an active DSM-V Axis I diagnosis of opioid use disorder.

admission criterion 1

Withdrawal history: Have a history of opioid withdrawal and/or symptoms of opioid withdrawal.

admission criterion 2

Regulatory compliance: Meet all appropriate Drug Enforcement Agency (DEA) and Department of Public Health (DPH) regulations.

admission criterion 3

Risk and need for medication: Have a sufficiently acute risk of relapse or continued opiate dependence requiring medication prophylaxis, regular counseling, and individualized urine monitoring.

Community Based Narcotic Treatment — Continuation Criteria

Continuation of opioid treatment services covered when ALL of the following are met

Continued meet criteria: Continue to meet admission criteria.

continued criterion 1

Appropriate level of care: A different level of care is not appropriate.

continued criterion 2

Symptom intensity: Experience symptoms of such intensity that, if discharged, would require a more intensive level of care.

continued criterion 3

Individualized treatment planning: Receive individualized and specific treatment planning, including provider orders, special procedures, contraindications, and other medications; treatment plans must document coordination with state agencies, caregivers, and family as appropriate.

Opioid Treatment Admission Exceptions

Admission criteria for opioid treatment services (selected conditions from this part of document):

Opioid treatment admission special cases: Members who previously received medications for opioid use disorder without evidence of current physical dependence and/or recent relapse may be re-admitted if there is a documented risk for opiate use and/or recent relapse.

admission exception

Youth admission: Members younger than 18 may be admitted if pregnant or have two documented unsuccessful attempts at short-term detoxification or drug-free treatment within the previous 12 months.

youth admission exception

Opioid Treatment Continuation

Continuation of opioid treatment services — covered when ALL of the following are met

Continuation criteria: 1) Continue to meet admission criteria; 2) A different level of care is not appropriate; 3) Symptoms of such intensity that discharge would require more intensive care; 4) Receive individualized and specific treatment planning; 5) When appropriate, consider medication trials; 6) Ensure different treatments if symptoms change or no progress; 7) Have strategies for treatment changes; 8) Document coordination with state agencies, caregivers and family and attempt to discharge or move to a lower level of care.

consolidated continued stay elements

Opioid Treatment Discharge

Discharge from opioid treatment services — discharge when ONE of the following is met

Discharge criteria: 1) Achieve treatment goals; 2) Have a support system that agrees to follow through with care and able to be in a less-restrictive environment; 3) Have all appropriate community-based linkages in place and functioning; 4) Withdraw consent for treatment (or a parent/guardian withdraws consent); 5) Do not appear to be participating in the treatment plan or are not making progress toward goals with little to no expectation for progress.

discharge conditions

Outpatient Psychotherapy Medical Necessity

Outpatient psychotherapy is reasonable and medically necessary when EITHER 1 or 2 of the following are met:

Psychotherapy criteria option 1: Meet ALL: a) clinical data show clear evidence of signs/symptoms consistent with DSM/ICD mental health or substance use disorder; and b) there is a treatment plan with measurable goals and approaches consistent with professional practice standards; and c) there is no less intensive or more appropriate level of service that can be safely and effectively provided.

psychotherapy option 1

Psychotherapy criteria option 2: Clinical data indicate the Member's condition has stabilized and continued treatment at a less frequent maintenance level is needed to sustain current level of functioning.

psychotherapy option 2

Extended Family Planning (EFP) services are excluded from coverage and should not be billed under this behavioral health outpatient policy. Additionally, the policy identifies specific applicable lines of business and program exclusions; providers should confirm member eligibility against the listed lines of business before billing (see applicable lines of business in policy).

Members cannot be enrolled in the IHH/ACT and Certified Community Behavioral Health Clinic (CCBHC) programs within the same month. CCBHC services for Medicare‑Medicaid Plan (MMP) members are an out‑of‑plan benefit and must be accessed via Medicaid fee‑for‑service rather than through Neighborhood; failure to follow these access rules may lead to denial.

Services are excluded when the member requires a level of structure and supervision above or below the scope of the requested services, or when the member has medical conditions or impairments that would prevent beneficial utilization of the services. The policy also excludes services that are not the most effective course of treatment for the client’s condition, or that are duplicated by same/similar services, and requires that requested services be provided in accordance with an approved treatment plan.

For many programs described in this policy, members must be 18 years or older. Exceptions to the age requirement are limited and specific (for example, certain opioid treatment exceptions for youth); providers must verify age eligibility against program‑specific admission rules before initiating services.

Services that can be provided safely and effectively at a lesser frequency or intensity are not covered. In particular, outpatient therapy visits that occur more than once per week are generally excluded, except in narrowly defined circumstances such as brief periods of acute crisis or when Dialectical Behavioral Therapy (DBT) is provided up to twice per week. Providers should document clinical justification when requesting or delivering exceptions.

Billing Codes and Code-Level Details

Covered CPT Codesmixed

No codes listed

Provider Responsibilities, Documentation, and Authorization

Billing Rule

CCBHC Billing / Access Requirements

Certified Community Behavioral Health Clinics (CCBHCs) must follow EOHHS regulations and the EOHHS CCBHC Provider Billing Manual when billing. For MMP members, CCBHC services are an out-of-plan benefit and must be accessed directly through Medicaid fee-for-service (not through Neighborhood).

CCBHCs must comply with all applicable EOHHS requirements
MMP members: access CCBHC benefit via Medicaid fee-for-service (out-of-plan)
Follow the EOHHS CCBHC Provider Billing Manual for billing procedures

Prior Authorization

Prior Authorization Access

Prior authorization request forms and assistance are available on Neighborhood's website and by phone. Providers must use the published forms and follow the Authorization Quick Reference Guide for coding guidance.

Level-of-Care Definitions and Criteria

Opioid Treatment Services / Community Based Narcotic Treatment — level-of-care criteria

Level-of-care criteria for Opioid Treatment Services / Community Based Narcotic Treatment

Admission criteria (level of care): Admission when ALL: active DSM-V opioid use disorder; history of opioid withdrawal; DEA and DPH regulations met; acute risk of relapse/continued dependence requiring medication prophylaxis, counseling, and individualized urine monitoring; biomedical complications requiring medical monitoring and skilled care.

level-of-care admission summarized

Continued stay criteria (level of care): Continue to meet admission criteria; different level of care not appropriate; symptoms would require higher care if discharged; individualized treatment planning and coordination; providers consider medication trials and ensure alternative treatments if no progress.

level-of-care continued stay summarized

Discharge criteria (level of care): Discharge when ONE of: achieve treatment goals; adequate support system for less-restrictive environment; community linkages in place and functioning; withdraw consent; lack of participation or progress with little expectation for improvement.

Specified Treatment Modalities

Medication for Opioid Use Disorder (MOUD) — modality criteria / notes

Medication for Opioid Use Disorder (MOUD) modality and notes

MOUD combined services: Medication for opioid use disorder provided in combination with counseling, medical screening, urine toxicology/testing, HIV/AIDS education, care management, and other appropriate services; may include Methadone Maintenance, Buprenorphine, and Suboxone.

MOUD service composition

DBT — Dialectical Behavioral Therapy modality and exception to visit limits

DBT modality and exception to visit limits

DBT frequency exception: Dialectical Behavioral Therapy (DBT) may be provided up to twice per week for outpatient services when appropriate, and brief increased frequency may be allowed for acute crisis periods.up to 2x/week

DBT exception to weekly visit limit

Session Lengths, Frequency, and Visit Limits

Clubhouse — minimum 3 hours per session

Minimum session lengthClubhouse services should include a minimum of three (3) hours per service, at least 1 time per week.

FrequencyAt least once per week (with activity plan developed within 1 week of start).

Documentation requirementActivity plan and records must be signed by provider and member; include at least weekly progress notes addressing each service provided.

Outpatient psychotherapy frequency limits — Therapy visits more than once per week are generally not covered (exception: DBT up to 2x/week or brief acute crisis periods)

General frequency limitTherapy visits more than once a week are generally not covered.

DBT exceptionDialectical Behavioral Therapy (DBT) may be provided up to twice per week when appropriate.

Program and Service Definitions

Clubhouse — definition: outpatient rehabilitative program for adults recovering from severe and persistent mental illness

DefinitionClubhouse: an outpatient rehabilitative program for adults recovering from severe and persistent mental illness using a work-ordered day and member-staff collaborative operations.

Core componentsIncludes work-ordered day tasks (e.g., clerical, food service, transportation), transitional/supported employment, community supports (housing, medical), educational assistance, and social programs.

Program operationsTypically open at least 5 days a week; members participate in governance and the program emphasizes community integration and employment at prevailing wages.

CCBHC — Certified Community Behavioral Health Clinic definition and certification reference

DefinitionCCBHC: a specially designated clinic that complies with SAMHSA certification standards and is certified by BHDDH to provide coordinated, comprehensive behavioral health and substance use services regardless of ability to pay or severity.

Background and Rationale

The policy emphasizes a recovery‑oriented, integrated approach to care for members with serious mental illness, focusing on coordination of behavioral and physical healthcare, chronic condition monitoring, timely post‑discharge follow‑up, and services that support self‑care, wellness, and community integration. Specialized programs (e.g., Clubhouse, Supported Employment, CCBHC, and opioid treatment services) are intended to provide comprehensive supports that improve access and reduce overall costs while addressing both behavioral health needs and related medical conditions.

Policy Dates and Review History

2025-09-01effective_dateLatest

Policy effective date set to 09/01/2025.

2025-08-20last_review

Policy last reviewed and Medical Director approval recorded on 08/20/2025.

2025-08annual_review_month

Policy assigned an annual review month of August and is reviewed annually.

OpenPayer

Behavioral Health Outpatient Services — Coverage Criteria