CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Hasbro Partial Program (Pediatric Partial Hospitalization) — Coverage Criteria

Defines medical necessity criteria and authorization process for admission, continued stay, and discharge for the Hasbro Partial Program, a pediatric day partial hospitalization program for children with co-occurring medical and psychiatric/behavioral health needs. Applies to providers seeking authorization for Neighborhood Health Plan of Rhode Island members across listed lines of business.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyHasbro Partial Program (Pediatric Partial Hospitalization) — Coverage Criteria

Policy CodePolicy N/A

Change TypeAnnual review — no material changes

Effective DateApr 9, 2025

Next Review DateApr 9, 2025

Key ActionSubmit medical necessity documentation to Neighborhood Utilization Management for prior authorization using the provider website forms or phone contact.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5Admission criteria items

4Continued stay items

MultipleLines of business

ExcludedEFP status

Annual

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Admission and Continued Stay Criteria

Initial Admission Criteria

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

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

Criteria 1-4 must be met

Recommended Pre-Admission Consideration

Recommended (not mandatory):

Recommended criterion: Other appropriate settings for treatment have been maximized, have failed, or are not available (e.g., acute hospital, home environment, group home).

Recommended but not mandatory per policy text

Continued Stay Criteria

Authorization for a continued stay must meet the following:

Continued stay criteria: 1) The child continues to meet admission criteria, and less intensive care is not appropriate; 2) The goals and progress are being monitored, and documentation demonstrates progress towards goals; 3) The member and/or family are compliant with the treatment plan; 4) Active discharge planning is ongoing, and documentation demonstrates the goal of transitioning the child to a less intensive level of care.

All items required for continued authorization

The policy explicitly excludes coverage for Extended Family Planning (EFP) services.

Program Level of Care / Partial Hospitalization

Referenced Codes

Covered Codes referencedmixed

No codes listed

Prior Authorization and Documentation Requirements

Prior Authorization

Prior Authorization Required

Prior authorization and medical review are required. Submit medical necessity documentation to Neighborhood Utilization Management via Neighborhood's prior authorization process to request authorization.

Submit complete medical necessity documentation to Neighborhood Utilization Management for review and authorization.
Use Neighborhood's prior authorization forms available at www.nhpri.org (Providers > Provider Resources > Forms) or call 1-800-963-1001 for assistance.
Approval is conditional and based on medical necessity review.

Denial Risk

Clinical Instability — Escalation / Denial Risk

If the medical co-morbid conditions are unstable, the provider must send medical necessity documentation to Neighborhood Utilization Management to request authorization. If documentation is not provided or medical comorbidities are clinically unstable without notification, follow Neighborhood escalation and potential denial guidance.

Program Definition and Scope

Hasbro Partial Program — key facts and admission requirements

Program definitionDay partial hospitalization program for children with both medical and psychiatric/behavioral health conditions requiring interdisciplinary team management.

Admission requirement (1)The child has active medical and active behavioral health diagnoses, which are treatable in partial hospital settings.

Admission requirement (2)Any psychiatric or behavioral condition where the child is at risk for deterioration in status, and/or potential risk for inpatient facility admission.

Admission requirement (3)The medical condition is unstable and cannot be managed in home environment secondary to psycho-social or environmental barriers.

Admission requirement (4)The child and parent/guardian have capacity for reliable attendance and active participation in all phases of the treatment.

Program Background

The Hasbro Partial Program is a pediatric day partial hospitalization program for children who have both medical and psychiatric/behavioral health conditions that require interdisciplinary team management. It is intended for situations where medical comorbidities are unstable and cannot be managed safely in the home because of psychosocial or environmental barriers, or when psychiatric/behavioral risk raises concern for deterioration or need for inpatient care.

Admission and continued-stay determinations require documentation that the child’s conditions are treatable in a partial hospital setting, that psychiatric risk or medical instability justifies this level of care, and that the child and parent/guardian can reliably attend and actively participate in the program’s treatment activities.