Optum Kansas Medicaid Behavioral Health Coverage | OpenPayer

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Optum Kansas Medicaid Behavioral Health Coverage | OpenPayer

inv-01: Attendant Care - Admission Criteria

Covered when ALL of the following are met

Attendant Care admission criteria: Member is not in a hospital, nursing facility, intermediate care facility for persons with mental retardation, or an institution for mental diseases; requires assistance performing tasks or engaging in activities (direct support/supervision/cuing; assistance with ADLs/IADLs and maintaining daily routines critical to residing in home/community); likely to need inpatient services without Attendant Care; recommended by the member's treatment team; not in imminent/current risk of harm to self, others, or property; co-occurring behavioral health or medical conditions can be safely managed; member and family willing and available to actively participate; care is medically necessary; children meet SED criteria; adults meet SPMI criteria.

From Attendant Care Admission Criteria

inv-02: Community Psychiatric Support and Treatment (CPST) - Admission Criteria

Covered when ALL of the following are met

CPST admission criteria general: Member has a behavioral health condition meeting criteria for a qualified DSM diagnosis causing reduced functioning and subjective distress; care is medically necessary; less intensive services would be inadequate to achieve treatment goals; co-occurring mental health, substance use, or physical conditions can be safely managed; member is willing and able (in collaboration with CPST provider) to connect with natural supports, community resources and activities to enable community integration.

From CPST Admission Criteria

CPST additional SPMI/SED requirements: Adults with SPMI must also meet the State's SPMI criteria; children/adolescents must meet the State's SED criteria in addition to the general CPST admission requirements.

From CPST Admission Criteria

inv-03: Community Based Wraparound Facilitation - Admission and Service Delivery Criteria

Covered when ALL of the following are met

Wraparound admission/documentation: Services for children and youth include communication and coordination with the family and/or legal guardian (and any agency legally responsible for the child); coordination with other child-serving systems as needed to achieve treatment goals; all coordination documented in the waiver member's medical record; providers receive ongoing and regular clinical supervision by a QMHP with supervision available at all times; a provider may perform 30 minutes of Case Conference during a Wraparound Facilitation meeting.

From Wraparound Admission Criteria

Wraparound service delivery: Facilitator guides Plan of Care development, reassembles the team for Plan of Care review at least yearly or more frequently as needed, emphasizes collaboration and coordination among family, caretakers, providers and community resources, and facilitators complete specialized training; service must not duplicate other Medicaid State Plan services available at no cost.

From Wraparound Service Delivery

inv-04: Independent Living / Skills Building - Admission and Service Delivery

Covered when ALL of the following are met

Independent Living admission: Services include communication and coordination with family/legal guardian and other child-serving systems as needed with documentation in the member record; services are provided in community settings and individualized in the Plan of Care; providers receive QMHP-level supervision as required.

From Independent Living Admission Criteria

Independent Living service limits: Services include training and cueing for normal ADLs and IADLs and community-based activities; housekeeping, homemaking (shopping, childcare, laundry) or basic services solely for convenience are not covered; transportation between residence and community service sites is provided and included in the provider rate.

From Independent Living Service Delivery

inv-05: Intensive Community Residential Placement (ICRP) - Admission Criteria

Covered when ALL of the following are met

ICRP admission: A DLA-20 screening has been completed by a certified screener indicating the member's level of need; member has history of unsuccessful integration in multiple community settings OR there is risk of harm to self or others such that without ICRP the member would require long-term psychiatric care or incarceration; member can tolerate regular interactions with peers; significant difficulties with ADLs; member may require round-the-clock observation/oversight and/or redirection for potentially harmful behaviors; behaviors directly interfere with ability to obtain or sustain independent living in the community.

From ICRP Admission Criteria

inv-06: Intensive Community Integration (ICI) - Admission Criteria

Covered when ALL of the following are met

ICI admission: An ADLA-20 (DLA-20) screening has been completed by a certified screener indicating level of need; member is unable to tolerate congregate living that precipitates psychiatric or substance use relapse, aggression, re-hospitalization, or incarceration; member may be competent in ADLs but has difficulty managing socially appropriate behavior skills needed for permanent housing; requires direct care staff to prevent harmful behaviors or high risk of relapse that interfere with independent living.

From ICI Admission Criteria

inv-07: Admission Criteria — Intensive Community Residential Placement (ICRP)

Member meets ALL of the following for ICRP admission:

ICRP admission: DLA-20 screening completed by a certified screener indicating level of need; history of unsuccessful integration in multiple community settings OR risk of harm to self/others that would require long-term psychiatric care or incarceration without ICRP; able to tolerate regular interactions with peers; significant difficulties with ADLs; may require round-the-clock observation/oversight and/or redirection for harmful behaviors; behaviors directly interfere with ability to obtain or sustain independent living in the community.

inv-08: Admission Criteria — Intensive Community Integration (ICI)

Member meets ALL of the following for ICI admission:

ICI admission: DLA-20 screening completed by a certified screener indicating level of need; unable to tolerate congregate living which precipitates relapse/aggression/re-hospitalization or incarceration; may be competent in ADLs but has difficulty managing socially appropriate behaviors needed for permanent housing; requires direct care staff to ensure member is not engaging in harmful behaviors and to prevent high-risk relapse interfering with independent living.

inv-09: Admission Criteria — Parent Support and Training (PST)

Member/child eligibility for PST requires ALL of the following:

PST admission: Member resides with or receives regular care from a family member; services include communication and coordination with the family; coordination with other child-serving systems as needed with all coordination documented in the medical record; member and family willing and available to actively participate in interventions identified in the Plan of Care; no imminent risk of serious harm to self or others; co-occurring mental health, substance use, and medical conditions can be safely managed; providers receive ongoing QMHP supervision available at all times; services are recommended by the treatment team and are subject to prior approval.

From PST Admission Criteria

inv-10: Admission Criteria — Professional Resource Family Care

Member eligibility and limitations for Professional Resource Family Care:

Professional Resource Family Care admission: Provides intensive family-based support in a surrogate family setting to address acute or chronic mental health needs and coordinate return to the family; regular contact with the family to prepare for return; member, family, and professional resource family are integral to the treatment team; transportation between residence and community service sites provided and included in provider rate; cannot be provided simultaneously with Short-Term Respite Care; not available to members in out-of-home placement via Child Welfare Contractors; does not duplicate other Medicaid State Plan services available at no cost; providers must document coordination and receive QMHP-level supervision as required.

From Professional Resource Family Care Admission and Service Delivery

inv-11: Admission Criteria — Psychiatric Residential Treatment Facility (PRTF)

Child must meet ALL of the following for PRTF admission:

PRTF basic eligibility: Child is under age 22; current signs and symptoms meet DSM diagnostic criteria not solely due to IDD or substance use; community resources/intensive community services have been determined unable to meet treatment needs in the past 30 days as evidenced by either: (1) participation in intensive community services for at least 30 days including psychotherapies, psychiatric medication treatment, and rehabilitative services without substantive improvement, OR (2) inability to utilize community services due to multiple inpatient admissions, frequent moves, severity of behaviors, or exhausted family/school/community efforts.

From PRTF Admission Criteria

PRTF acute risk evidence (past 60 days): In the past 60 days, behaviors have caused multiple episodes of acute risk of substantial harm to self or others or inability to care for physical health/safety, evidenced by TWO or more of listed items (e.g., aggressive/assaultive behavior causing harm, inability to maintain behavioral control >48 hours, pervasive rejection of adult direction risking harm, psychotic symptoms causing dysfunction, fire setting, chronic injurious behaviors, chronic suicidal/homicidal ideation/behaviors, repeated arrests related to psychiatric diagnosis, poor impulse control unresponsive to adults, runaway placing self at risk, high-risk sexual behavior, eating disorder safety issues, substance use exacerbating psychiatric symptoms).2 of listed items

inv-12: Continued Stay Criteria — PRTF

For continued stay in PRTF, ALL of the following apply:

PRTF continued stay basic: Child is under age 22; current signs and symptoms meet DSM diagnostic criteria not solely due to IDD or substance use; there is substantial chronic risk of harm to self or others or inability to care for physical health/safety not manageable at a lower level of care, as evidenced by meeting at least ONE listed behavior in the past two weeks in any setting (e.g., aggressive or assaultive behavior, hostile/threatening behavior, need for intensive staff interventions to contain dysregulation, need for external controls for impulsiveness or self-care, treatment-rejecting behavior, pervasive suicidal/homicidal ideation/action, psychotic symptoms impacting daily living, medication regimen still being adjusted causing risk); PRTF services are reasonably expected to produce clinically significant improvement and benefits outweigh negatives including family separation.At least one listed behavior in past 2 weeks

From Continued Stay Criteria

PRTF treatment standards: Clinical best practices are being provided with sufficient intensity to meet the child's treatment needs and regulatory requirements; PRTF team has collaborated directly with community providers to facilitate transition prior to discharge.

From Continued Stay Criteria

inv-13: Service Delivery — Operation Community Integration / OCI services

Services are covered when they are person-centered, medically necessary, and directly related to community integration and housing stability:

OCI core principles: Services follow the Housing First model and support access to safe, affordable housing; daily programming and face-to-face interventions support community integration and housing stability; services are client-driven, individualized for diverse populations (including transition-age youth, elders, persons with criminal records, homeless families), and target housing readiness, quality of life, health, behavioral health, and employment barriers.

From OCI Service Delivery core principles

OCI service components: Services may include assistance with ADLs and social skills, symptom management coaching, conflict resolution, HUD coordinated entry collaboration, recovery coaching and relapse prevention, case management for housing supports, landlord/tenant dispute resolution, entitlement/SOAR advocacy, budget development/management support, legal barrier referral, anger management interventions guided by SAMHSA CBT workbook, medication management including Medication Assisted Treatment, housing searches and applications, coordination with social supports, IPS supported employment, housing crisis planning, and mobile crisis response/collaboration with CIT teams.

From OCI Service Delivery components

inv-14: Service Delivery — Parent Support and Training interventions

Covered interventions for PST include:

PST evaluation and planning: Active engagement of member and family in evaluation, planning and decision-making with consent; assessment of family strengths/limitations, priorities, relationship quality, cultural/spiritual considerations, and family members' own mental health needs with referrals as appropriate; the service plan summarizes family goals and coordinates treatment elements and ensures coordination of all elements of treatment and rehabilitation.

From PST Evaluation and Treatment Planning

PST interventions: Develop an explicit crisis plan and professional response; improve family communication and structured problem-solving training; expand family social supports and provide flexible access to professionals; train family on diagnosis, waiver/process navigation, and assist with skill acquisition for symptom and behavior management; provide follow-up regarding services and continuing needs.

From PST Service Delivery Interventions

inv-15: Continued Stay Criteria (PRTF) — Continued stay in PRTF is covered when ALL of the following are met

Continued stay in PRTF is covered when ALL of the following are met:

Continued stay core requirements

Risk/functional/medical behaviors within past 2 weeks: There is a substantial chronic risk of harm to self or others, or inability to care for physical health and safety, as evidenced by meeting at least ONE of a list of behaviors in the past two weeks (e.g., aggressive behavior, pervasive suicidal ideation/action, psychotic symptoms, requirement for intensive staff interventions or external controls, treatment-rejecting behavior, pervasive rejection of adult requests, medication adjustments causing risk).>=1 in past 2 weeks
List appears in Continued Stay Criteria

inv-16: Discharge Criteria — Discharge from PRTF is appropriate when ONE or more of the following high-level conditions occur, with specific stabilization criteria

Discharge from PRTF is appropriate when ONE or more of the following high-level conditions occur, with specific stabilization criteria

Treatment no longer requires PRTF due to stabilization

Risk status acceptable: For at least two weeks: no suicide plan or act of serious self-harm; thoughts of suicide/homicide absent or manageable at a lower level of care; cooperative behavior with defiance/aggression absent or manageable at a lower level of care.2 weeks
From Discharge Criteria
Functional status acceptable: For at least two weeks: child responds to limits by using coping skills or asking for support; stays emotionally regulated or can be managed at a lower level of care; for at least four weeks: demonstrates safety during onsite visits and off-site passes or no more risky behavior than family can manage; child can collaborate with adults, attend school and participate in recommended community treatment; family/supports can manage behavior and are willing to participate.2-4 weeks

Attendant Care and Independent Living/Skills Building housekeeping, homemaking, and basic convenience services are not covered. Specifically, housekeeping, homemaking (shopping, childcare, and laundry services), or basic services solely for the convenience of a member receiving Independent Living/Skills Building are excluded. Additionally, Attendant Care is not covered when provided to a member who is in a hospital, nursing facility, intermediate care facility for persons with mental retardation, or an institution for mental diseases.

Admission to a Psychiatric Residential Treatment Facility (PRTF) excludes members who are acutely suicidal, acutely homicidal, or acutely psychotic unless the specific PRTF can safely manage those conditions. The document notes that such acute presentations are excluded unless the PRTF has the capacity to provide care in such situations (for example, 1:1 staffing, crisis management, and 24/7 nursing and physician coverage).

Short Term Respite Care has specific limitations: it may not be provided simultaneously with Professional Resource Family Care services; it is not available to members in foster care because those recipients access respite through child welfare contractors (it may be provided to members in DCF or JJA custody who are living at home); and it must not duplicate any other Medicaid State Plan service or services otherwise available to the recipient at no cost.

Attendant Care is not covered when the member is receiving care in institutional settings. The policy states that Attendant Care is not covered when provided to a member who is in a hospital, nursing facility, intermediate care facility for persons with mental retardation, or an institution for mental diseases.

Level of Care and Residential Criteria

inv-45: Intensive Community Residential Placement (ICRP) — Level-of-care criteria

ICRP level-of-care criteria: DLA-20 screening completed by a certified screener indicating level of need; history of unsuccessful integration in multiple community settings OR risk of harm to self/others such that without ICRP the member would require long-term psychiatric care or incarceration; able to tolerate regular interactions with peers; significant difficulties with ADLs; may require round-the-clock observation/oversight and/or redirection for harmful behaviors; behaviors directly interfere with ability to obtain or sustain independent living.

From ICRP Admission Criteria

inv-46: Intensive Community Integration (ICI) — Level-of-care criteria

ICI level-of-care criteria: ADLA-20/DLA-20 screening completed by a certified screener indicating level of need; member unable to tolerate congregate living which precipitates relapse/aggression/re-hospitalization/incarceration; may be competent in ADLs but has difficulty managing socially appropriate behaviors needed for permanent housing; requires direct care staff to prevent harmful behaviors or high-risk relapse that interferes with independent living.

From ICI Admission Criteria

inv-47: Residential / PRTF / ICRP / ICI — Level-of-care criteria group

Residential / PRTF / ICRP / ICI level-of-care grouping: See individual level-of-care nodes: ICRP (DLA-20 screening, unsuccessful community integration or risk of harm, ADL deficits, potential need for 24/7 observation), ICI (DLA-20 screening, inability to tolerate congregate living, social behavior deficits requiring direct care), and PRTF (under 22, DSM diagnosis not solely due to IDD/substance use, failed or inaccessible community services, acute risk evidence).

Aggregated grouping from multiple admission criteria

inv-48: PRTF / Residential — Level-of-care criteria (PRTF/Residential grouping)

PRTF / Residential level-of-care criteria: Child under 22; DSM diagnosis not solely due to IDD/substance use; substantial chronic risk behaviors or inability to care for physical health/safety present and not manageable at lower level of care; clinical best practices provided with sufficient intensity; treatment reasonably expected to produce clinically significant improvement; documentation of coordination with community providers and QMHP supervision as required.

From PRTF / Residential continued stay and admission criteria

Provider Responsibilities and Authorization

Documentation Required

Screening requirement for ICRP/ICI

A certified screener must complete the DLA-20 or ADLA-20 screening tool to document the member's level of need prior to admission to ICRP or ICI. A copy of the completed screening tool, the screener's recommendations, and a treatment plan created within 72 hours of admission must be included in the member's record and used to support continued stay reviews.

DLA-20 or ADLA-20 completed by a certified screener prior to admission
Copy of the DLA-20/ADLA-20 and screener recommendations required in chart
Treatment plan completed within 72 hours of admission and reviewed monthly

Prior Authorization

Prior Authorization Required for PST and Professional Resource Family Care

Parent Support and Training (PST) and Professional Resource Family Care require recommendation by the member's treatment team and are subject to prior approval. These family- and resource-based services must be medically necessary and aligned with the child's individualized plan of care.

PST: recommended by treatment team and subject to prior authorization
Professional Resource Family Care: team recommendation and prior authorization required

Billing Rule

Wraparound Duplication Prohibition and Coordination Requirements

Wraparound Facilitation is intended to augment care and must not duplicate services available under the Medicaid State Plan or other services available to the member at no cost. The wraparound facilitator must emphasize coordination among the family, caretakers, service providers, and other formal and informal community resources and document coordination activities in the member's record.

Wraparound Facilitation must not duplicate other Medicaid State Plan services
Facilitator documents coordination and team activities in the waiver member's medical record
Facilitator coordinates Plan of Care development and reassembly of team as needed

Denial Risk

Admission Denial Risk if Intensive Community Services Not Tried or Not Appropriate

If community resources or intensive community services have not been tried or are not appropriate (e.g., intensive community services were not provided for at least 30 days or the child's condition prevents utilization of community services), admission to PRTF or denial of admission may be warranted. Reviewers and providers should ensure documentation shows that available intensive community services were attempted and unsuccessful or that the child could not reasonably access those services.

Evidence that intensive community services were tried for at least 30 days and did not produce substantive improvement OR documentation that community resources were not accessible in the past 30 days
If community resources/intensive community services were not tried or behavioral risk criteria unmet, admission may be denied

Denial Risk

Continued Stay Denial Conditions

Continued stay may be denied if the child does not demonstrate the required substantial chronic risk behaviors or inability to care for personal health and safety at the level specified for PRTF continued stay. Continued stay criteria must be documented and updated, showing the child meets at least one of the listed high-risk behaviors within the prior two weeks and demonstrating that PRTF services are reasonably expected to produce clinically significant improvement.

Continued stay requires documentation of substantial chronic risk behaviors within the past two weeks (see Continued Stay Criteria)
If the child does not meet continued stay criteria or is not benefiting from services, continued stay may be denied

Documentation Required

Coordination with Family and Child-Serving Systems; Documentation Requirements

Providers must coordinate with the family, legal guardian, and other child-serving systems (schools, CBST, outpatient providers) as needed to achieve treatment goals. All coordination, communication, and planning activities must be documented in the youth's medical record and the waiver member's record as applicable.

Document communication and coordination with family/guardian and other child-serving systems in the member's medical record
Include input from family and collaterals in periodic service plan reviews
Coordinate with schools, CBST, and community providers for discharge and ongoing care

Note

Reviewer Responsibilities — Eligibility, Benefits, and Regulatory Requirements

All reviewers must identify member eligibility, the member-specific benefit plan coverage, and any applicable federal or state regulatory requirements before applying these clinical criteria. Where the member's benefit plan limits or excludes a service, the member-specific benefit supersedes the Clinical Criteria.

Reviewer responsibility to confirm member eligibility and benefit coverage prior to authorization decision
Identify federal/state regulations that supersede member benefits

Documentation Required

PRTF Admission Documentation Requirement — Intensive Community Services Attempted

For PRTF admission, documentation must show that intensive community services were tried for at least 30 days without substantive improvement OR document that the child's psychiatric/psychosocial condition prevented utilization of community services. Admission records should include the required admission evidence and safety/progress documentation as applicable.

Evidence that intensive community services were attempted for ≥30 days and failed to produce substantive improvement, or documentation of inability to access community services
For ICRP: safety log entries and progress notes reflecting safety monitoring; for ICI: critical intervention plan in the member file
Admission documentation may be denied if community resources/intensive community services were not tried

Documentation Required

Transition and Discharge Planning Requirement

Discharge and transition planning must prepare the child, family, school, and community providers with sufficient lead time (for example, setting the discharge date two weeks or more in advance). The PRTF team must schedule follow-up appointments within two weeks of discharge and directly collaborate with community and outpatient providers to ensure continuity of medication, therapy, and supports.

Set discharge planning and transition tasks with ≥2 weeks lead time when possible
Follow-up appointments (therapy, med management, medical care, rehabilitative services) scheduled within 2 weeks of discharge
PRTF team must communicate directly with outpatient medical and therapy providers prior to discharge

Screening, Timelines, and Coding Notes

DLA-20 / ADLA 20 screening — Completed by a certified screener to indicate member's level of need

ToolDLA-20 (also referenced as ADLA 20) screening completed by a certified screener to indicate the member's level of need for ICRP/ICI.

Who completes itA certified DLA-20 screener.

PurposeIndicates level of need to support admission to Intensive Community Residential Placement (ICRP) or Intensive Community Integration (ICI).

Treatment plan completion timeframe — Treatment plan must be completed within 72 hours of admission

Required timeframeTreatment plan must be completed within 72 hours of admission.

DocumentationCopy of the DLA-20 screening tool and the treatment plan must be placed in the member's chart.

Review frequencyTreatment plans must be modified/updated as necessary and reviewed with the treatment team monthly (proof placed in chart).

Intensive community services trial duration — Intensive community services should be tried for at least 30 days

Minimum durationIntensive community services should be tried for at least 30 days.

Components of trialIncludes psychotherapies (individual, family, group), psychiatric medication treatment, and rehabilitative services (e.g., SED waiver, Psychosocial Rehab, CPST).

Evidence requirementDocumentation that intensive community services were tried for ≥30 days or evidence that community services cannot be utilized is required for PRTF admission consideration.

Risk stabilization observation period — Minimum observation/stabilization period of at least two weeks for certain discharge criteria

Minimum observation periodRisk stabilization observation period of at least two weeks for multiple risk-related discharge subcriteria.

Functional safety timeframeSome functional safety items require up to four weeks (e.g., demonstrated safety during onsite visits and off-site passes).

Domains assessedRisk status, functional status, and medical needs must meet specified stabilization criteria over the minimum timeframes to support discharge from PRTF.

Key Definitions

Attendant Care — definition of attendant care service

DefinitionAttendant Care is a paraprofessional-delivered service to assist a child/adolescent with SED or an adult with SPMI to accomplish tasks or engage in activities they would normally do themselves.

Setting limitationNot covered when provided to a member who is in a hospital, nursing facility, intermediate care facility for persons with mental retardation, or an institution for mental diseases.

Training requirementDelivered by a paraprofessional who has completed state-approved training.

Community Psychiatric Support and Treatment (CPST) — definition

DefinitionCommunity Psychiatric Support and Treatment (CPST) are goal-directed, solution-focused, face-to-face supports and interventions intended to achieve goals in the member's individualized treatment plan.

Contact locationMajority of CPST contacts must occur in community locations where the member lives, works, attends school, and/or socializes.

ParticipantsInterventions are face-to-face with the member present; family or other collaterals may also be involved.

PRTF — Psychiatric Residential Treatment Facility definition

DefinitionPsychiatric Residential Treatment Facility (PRTF) is a sub-acute facility-based program delivering 24/7 assessment, diagnostic services, and active behavioral health treatment for children/adolescents with significant functional impairment.

Target populationChildren/adolescents whose psychiatric symptoms cause danger to themselves or others and for whom intensive community services have failed to keep them safe or prevent regression.

Service levelProvides continuous (24-hour/7-day) assessment and treatment under physician direction.

Operation Community Integration (OCI) / Housing First — definition

DefinitionOperation Community Integration (OCI) / Housing First is a service model focused on rapid access to housing and supports for community integration, emphasizing member choice, skill building, and linkages to community resources.

Core principlesFollows Housing First model with person-centered supports, housing access, daily programming, and individualized supports to address quality of life, health, behavioral health, and employment barriers.

Service componentsMay include assistance with ADLs, symptom management coaching, case management for housing supports, landlord/tenant advocacy, medication management (including MAT), IPS supported employment, and mobile crisis response collaboration.

Substantial chronic risk — definition of risk behaviors or conditions

DefinitionSubstantial chronic risk: behaviors or conditions present in the past two weeks not manageable at a lower level of care (e.g., aggressive/assaultive acts, pervasive suicidal/homicidal ideation or action, psychotic symptoms impacting daily living, need for external controls or intensive staff interventions, inability to care for physical health/safety).

Timeframe for evidenceRisk behaviors must be evident in the past two weeks in any setting to support continued PRTF stay.

ExamplesIncludes aggressive or assaultive behavior, pervasive rejection of adult requests, treatment-rejecting behavior, delusions/hallucinations, and medication regimen adjustments causing risk.