ModifiedOptumPolicy BH803KY012025

Kentucky Medicaid Supplemental Clinical Criteria — Behavioral Health

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State-specific clinical criteria and service requirements for behavioral health services under Optum Medicaid in Kentucky, governing medical necessity determinations and provider-level service delivery for covered behavioral health programs and levels of care.

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ModifiedOptumPolicy BH803KY012025

Kentucky Medicaid Supplemental Clinical Criteria — Behavioral Health

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Policy Summary

PayerOptum

PolicyKentucky Medicaid Supplemental Clinical Criteria — Behavioral Health

Policy CodePolicy BH803KY012025

Change TypeService additions, clarifications, and limits removed

Effective DateJan 1, 2025

Last ReviewJun 20, 2025

Next Review DateN/A

Key ActionDocument and retain treatment-plan reviews and required service contacts to support authorization and billing (e.g., 4 TCM contacts/month, age-specific PRTF review intervals).

SourceLink

POLICY UPDATE CHANGES

Psychoeducation services added; effective 01/01/2025.

Clarification of Peer Support Specialist role and that face-to-face services include audiovisual telecommunications.

Added Targeted Case Manager education requirements and training requirements.

Removal of annual limitations for Peer Support Services and Psychoeducation.

Added ACT services and LOCUS criteria information.

Multipleservice types

14 daysPRTF review (4-5 yrs)

10ACT caseload limit

4/moTCM unit requirement

25Max TCM caseload

1Psychoeducation added

Coverage and Medical Necessity Criteria

Behavioral Health Day Treatment - Admission criteria

Covered when ALL of the following are met:

Day Treatment admission: Member is under age 21 and has a mental health disorder, substance use disorder, or co-occurring mental health and substance use disorderage < 21

Member must have a high risk of out-of-home placement due to a behavioral health issue

Comprehensive Community Support Services - Admission

Covered when ALL of the following are met:

CCSS admission: Member has a primary mental health disorder or a co-occurring mental health and substance use disorder

Member requires skills training/support to live with maximum independence as identified in individualized treatment plan

Comprehensive Community Support Services - Continued Stay

Covered when ANY one of the following is present:

Continued stay: Desired functioning not restored OR at risk for relapse OR achieved current goals and additional goals are indicated OR making satisfactory progress where continuation will be effective OR making some progress but interventions need modification OR failing/regressing and requiring reassessment

Continuation requires documentation supporting effectiveness or need for reassessment

Comprehensive Community Support Services - Discharge

Discharge is appropriate when ANY one of the following is met:

Discharge: Improved functioning per treatment plan OR achieved positive life outcomes supporting stable living and no longer in need OR not making progress after exhausting strategies OR member no longer wishes service

Document discharge rationale in the treatment record

Psychiatric Residential Treatment Facility - Admission (Level I and II)

Covered when ALL of the following are met:

General PRTF admission: Member is under age 21 with a DSM-5 diagnosis and meets the KAR 3:130 definition of medical necessityage < 21

PRTF serves as an alternative to hospitalization and for transition from hospital settings

Level I criteria: Requires long-term inpatient psychiatric care or crisis stabilization more suitably provided in a PRTF than a psychiatric hospital and requires Level I services continuously due to severe mental or psychiatric illness

Level I denotes continuous need for PRTF-level care

Level II criteria: Child with severe emotional disability requiring long-term inpatient care or crisis stabilization better in a PRTF; requires Level II services due to severe emotional disability plus severe/persistent aggressive behavior, intellectual disability, sexually acting out behavior, or developmental disability; does not meet acute hospital criteria

Level II applies when needs exceed ambulatory care and Level I capabilities

Psychiatric Residential Treatment Facility - Continued Stay

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

Active treatment and treatment plan: Member is receiving active treatment and a treatment plan specifying amount/frequency of services and number of therapeutic pass days is developed

Treatment plan must document services and pass days

Level I review frequency: Level I PRTF must re-evaluate member at least once every 30 days and review treatment plan at least once every 30 days with dated signatures, progress assessment, and justification for level of servicesevery 30 days

Review must include dated signatures and justification for continued level

Level II initial and follow-up review: Level II PRTF must complete initial review by the third business day including dated signatures, progress assessment, and justification; for ages 4-5 review every 14 days after initial review; for ages 6-22 review every 30 days after initial reviewage-specific intervals

PRTF Continued Stay — documentation and review schedule

Documentation and review schedule for Level II continued stay:

Ages 4-5 Continued Stay: For members aged 4-5, complete a review of the treatment plan at least once every 14 days after the initial review.every 14 days

Review must include dated signatures, assessment of progress toward each treatment plan goal with revisions, and a statement justifying continued services and suitability for a less-restrictive environment.

Ages 6-22 Continued Stay: For members aged 6-22, complete a review of the treatment plan at least once every 30 days after the initial review.every 30 days

PRTF Discharge Criteria

Discharge requires a member-specific plan that addresses ALL of the following elements:

Discharge Plan Elements: Discharge plan must indicate member-specific behavioral indicators for discharge; expected service level after discharge; intended provider to deliver services upon discharge; a crisis action plan across the continuum; transition plan to lower intensity and discharge; an individual behavior management plan; a family involvement/visitation plan (unless court-prohibited); and services/planning beginning at admission to facilitate discharge to home-based services or a lower level of care.N/A

Includes therapeutic off-site visits per treatment plan

Peer Support Services Criteria — coordination, certification, plan alignment

Covered when ALL of the following are met:

Service Integration: Peer support services must be identified on the individualized treatment plan, be recovery-oriented, person-centered, voluntary, relationship-focused and trauma-informed, and designed to contribute directly to individualized goals; group size must not exceed 8 individuals.group size <= 8

Services are structured, scheduled, nonclinical therapeutic activities

Provider Qualifications - Peer Support Specialist: Peer Support Specialists must be employed by a Medicaid-enrolled provider or licensed organization and complete state-approved training and eligibility requirements per 908 KAR regs; youth peer supports require department-approved YPS 101 training and specified supervisory arrangements including documented face-to-face supervision meetings.as per 908 KAR regs

Supervision and training documentation must be maintained

Psychoeducation Criteria — scope, delivery, settings (individual/group)

Covered when ALL of the following are met:

Indications and Integration: Psychoeducation is appropriate for individuals with mental health or substance use conditions, their families, and support networks and must align with a person-centered individualized treatment plan; rationale and indication must be documented in the clinical record; when delivered as part of day treatment/TRP/IOP/PHP/residential it is included in per diem and must not be billed separately on the same day.N/A

Must be reflected in the treatment plan

Session Parameters: Number of sessions usually varies from 5 to 24; sessions typically last 40-60 minutes at weekly intervals; optimum group size is 8 individuals; sessions cover diagnosis, relapse prevention, coping skills, medication management, and related topics.5-24 sessions; 40-60 minutes; group size <=8

Brief structured intervention delivered individually or in groups

Targeted Case Management Criteria — billing unit, minimum contacts, population differences

Billing unit and minimum contact requirements — Covered when ALL of the following are met:

TCM Adults (SMI): A unit equals one month; at least 4 service contacts per month are required, with two face-to-face contacts (including audiovisual telecommunication) with the client; the other two contacts may be face-to-face or by telephone.>=4 contacts/month; >=2 face-to-face

One unit = one month for adults with SMI

TCM Children (SED): A unit equals one month; at least 4 service contacts per month are required, with two face-to-face contacts including at least one face-to-face with the child and one with the family/parent/custodial person; other two contacts may be face-to-face or by telephone.>=4 contacts/month; >=2 face-to-face (1 with child and 1 with family)

Special reimbursement rule applies for members under age 18

TCM for SUD:

TCM Admission Criteria (SMI/SED)

Admission for TCM (SMI/SED) — Covered when ALL of the following are met:

Eligibility Requirements: Member is an adult with SMI or a child with SED as defined in KRS 200.503(3); not 21-64 in an institution for mental disease or an inmate; needs assistance accessing housing, vocational, medical, social, educational or other community services; has involvement with child welfare/criminal justice or is in custody of Department for Community Based Services; or is at risk of out-of-home placement or inpatient mental health treatment.N/A

Member must have significant impairment in major areas of community living

Diagnostic Criteria: Member diagnosed with SMI using DSM-5 criteria in schizophrenia spectrum/psychotic disorders, bipolar disorders, depressive disorders, or PTSD; history indicates persistent disability or multiple hospitalizations or symptoms persisting >=2 years.N/A

Chronicity or hospitalization supports eligibility

TCM Admission (SMI/SED) — 'Covered when ALL of the following are met'

Covered when ALL of the following are met:

SMI/SED admission: Member is an adult with SMI or a child with SED as defined in KRS 200.503(3)

Institution/inmate exclusion: Member is not 21 to 64 years old while receiving services in an institution for mental disease or an inmate of a public institution

Needs assistance: Member needs assistance accessing housing, vocational, medical, social, educational, or other community services or supports

System involvement: Member has been involved with at least one child welfare or criminal justice agency or is in the custody of the Department of Community Based Services

TCM Admission (SUD)

Covered when ALL of the following are met:

Primary diagnosis: Member has a primary moderate or severe substance use disorder or co-occurring moderate or severe SUD and mental health diagnoses

Lack of supports: Member lacks access to supports necessary for recovery

Needs assistance: Member needs assistance accessing housing, vocational, medical, social, educational, or other community services

System involvement: Member is involved with child welfare or criminal justice agencies but is not an inmate of a public institution

Institution/inmate exclusion:

TCM Admission (Co-occurring with Chronic Physical Health)

Covered when ALL of the following are met for TCM with co-occurring chronic physical health:

SMI/SED criteria: Member meets SMI/SED diagnostic and impairment criteria as described for TCM

SUD criteria: Member is diagnosed with a moderate or severe substance use disorder per DSM criteria

Chronic/complex physical health diagnosis: Member has a chronic or complex physical health issue (cardiovascular, respiratory, genitourinary, endocrine, musculoskeletal, neurological, immune disorder, obesity, cancer, deafness, blindness)

Physical health chronicity/hospitalization: Clinically significant physical health symptoms persisting >=2 years OR hospitalized for the physical health issue >1 time in past 2 years

Therapeutic Rehabilitation Admission/Continued Stay — 'Covered when ALL of the following are met'

Covered when ALL of the following are met:

Population: Member is an adult with SMI or a child with SED who requires less than 24-hour care but more than outpatient counseling

Need for rehabilitation: Member requires a therapeutic program to develop, acquire, enhance, or maintain interpersonal, daily living, and personal adjustment skills

Day treatment services must be coordinated with the local education authority and align with the recipient's individualized education plan (IEP) or Section 504 plan. Day treatment shall not include a therapeutic clinical service that is included in a child's individualized education plan or Section 504 plan, and services are provided face-to-face on school days and scheduled breaks with a linkage agreement specifying responsibilities between the provider and local education authority.

Psychoeducation provided as a component of Day Treatment, Therapeutic Rehabilitation Program (TRP), IOP, PHP, or residential services is included in the per diem and must not be billed separately on the same day. Providers must not unbundle services that are bundled in the appropriate level of care; the rationale and indication for psychoeducation must be documented in the person-centered individualized treatment plan and clinical record.

Members who are between ages 21 and 64 while receiving services in an institution for mental disease, or who are inmates of a public institution, are excluded from these community-based services. Targeted case management and related community programs specifically disallow coverage for members in those institutional/inmate settings.

This document was updated through state reviews and interim revisions that add or clarify covered services and program requirements (for example, the addition of psychoeducation as a covered service effective 01/01/2025 and later removals of annual limitations). Providers should reference the revision history and state approvals to identify recent changes that may affect service limits, documentation expectations, or program definitions.

Discharge from a therapeutic program is appropriate when the member no longer wants, requires, or needs the service, or when symptom reduction indicates the member can transition to a lower level of care. For PRTF specifically, discharge planning must be member-specific and begin at admission; the discharge plan must identify behavioral indicators for discharge, expected post-discharge service level and receiving provider, a crisis action plan, transition steps to lower-intensity services, an individual behavior management plan, and family involvement/visitation arrangements as applicable. PRTF continued-stay reviews must document progress toward goals and justify continued placement prior to discharge planning decisions.

No explicit statements labeled “not medically necessary” are present in the cited document excerpts. Providers should use the criteria and discharge rules in the policy and reference member-specific benefits and state regulations when determining whether services are medically necessary.

Provider Requirements, Billing, and Documentation

Prior Authorization

Prior Authorization Required

Effective June 30, 2023, prior authorization is required for ASAM levels of care 3.1, 3.5, 3.7 and 4.0. Verify member eligibility and reference the member-specific benefit plan before requesting authorization; benefits or state/federal rules may supersede clinical criteria.

Prior authorization required for ASAM 3.1, 3.5, 3.7, 4.0
Confirm member eligibility and benefit coverage prior to authorization request
If member benefit excludes or limits service, benefit supersedes clinical criteria

Documentation Required

PRTF Continued Stay and Treatment Plan Review Documentation

PRTF (Psychiatric Residential Treatment Facility) continuing stay and treatment plan reviews must be completed at required intervals with dated signatures and documented clinical justification. Failure to complete these periodic reviews with signatures and justification may place continued authorization at risk.

Key Metrics and Code-Related Rules

PRTF Level I re-evaluation interval

IntervalLevel I PRTF: re-evaluated at least once every 30 days

Review elementsEach 30-day review must include dated signatures of appropriate staff (and parent/guardian if present), assessment of progress toward each treatment plan goal with revisions indicated, and a statement justifying the level of services needed

PurposeDetermine continued eligibility for Level I PRTF patient status and suitability for less-restrictive environment

ACT caseload ratio — max 10 participants per team member

Maximum ratioAssertive Community Treatment (ACT): caseload shall not exceed 10 participants per team member

Team staffingTeam must be multidisciplinary, led by an approved behavioral health services practitioner and include at least four full-time equivalents (prescriber, nurse, approved practitioner, case manager)

Level-of-Care Determination Rules

Community-based programs (ACT, Day Treatment, CCS) level-of-care criteria

Level-of-care considerations for community-based programs (ACT, Day Treatment, CCS):

Community-based programs level-of-care: Services (ACT, Day Treatment, Comprehensive Community Support) must be provided face-to-face and coordinated with individualized treatment plans; ACT teams require multidisciplinary staffing and caseload limits (no more than 10 recipients per team member).face-to-face; caseload <=10 per team member

Apply LOCUS for additional level-of-care determination

PRTF (Level I and Level II) level-of-care criteria

PRTF level-of-care criteria (applies to both Level I and Level II):

PRTF general LOC criteria: Member under 21 with DSM-5 diagnosis meeting state medical necessity requires inpatient-level PRTF care because needs cannot be met in ambulatory care or less restrictive settings; active treatment and documented treatment plan required.

Services and Modalities

Community-based psychiatric rehabilitation — modality node

Modalities and delivery expectations for community-based psychiatric rehabilitation:

Face-to-face delivery: Assertive Community Treatment, Day Treatment, and Comprehensive Community Support Services must be provided face-to-face and performed in accordance with individualized treatment plans; services include assessment, treatment planning, case management, therapy, crisis services, and skills training.face-to-face

Providers must coordinate with education services for day treatment when applicable

Peer Support and Psychoeducation modalities — two nodes

Modalities for Peer Support and Psychoeducation:

Peer Support modality: Peer support is delivered as structured, scheduled nonclinical therapeutic activities aligned with an individualized treatment plan; may be individual or group-based with group size not to exceed 8 individuals; providers must be trained/certified per state regs and supervised as required for youth peers.

Service Frequency, Unit, and Caseload Limits

Assertive Community Treatment (team caseload) — 10 recipients per team member

Team caseload limitAssertive Community Treatment (ACT): 10 recipients per team member (team caseload shall not exceed 10 participants per team member)

Staffing requirementBehavioral health organization must employ at least one multidisciplinary team led by an approved behavioral health services practitioner with at least four FTEs

DocumentationTeams must document and maintain individual case records and coordinate provision of services among team members

Peer support group size / psychoeducation optimum group size (<=8)

Optimum group sizePeer support group / psychoeducation optimum group size: up to 8 individuals

Session length (psychoeducation)

Background and Policy Scope

These clinical criteria codify Kentucky Administrative Regulations and contractual requirements used to determine medical necessity for behavioral health services. The policy references state regulations and the LOCUS (Level of Care Utilization System) tool and incorporates state-reviewed changes (for example, additions to services such as psychoeducation effective 01/01/2025, clarifications to peer support roles, and inclusion of ACT services). Providers must ensure documentation and service delivery align with Kentucky regulations and the LOCUS guidance when applying medical necessity determinations.

Key Definitions

PRTF definition

DefinitionPsychiatric Residential Treatment Facility (PRTF): a separate, standalone facility providing comprehensive long-term, intensive inpatient treatment for children and youth under age 21 under physician direction; serves as community-based alternative to hospitalization

PopulationServes children and youth under age 21, including those transitioning from hospitals who are not yet ready to return home or to foster care

Regulatory citationsDefined in federal regulations (42 CFR Parts 441 and 483) and Kentucky regulations (902 KAR 20:320 and 902 KAR 20:330)

Assertive Community Treatment (ACT) definition

DefinitionAssertive Community Treatment (ACT): an evidence-based psychiatric rehabilitation practice providing a comprehensive approach to service delivery for individuals with serious mental illness, including assessment, treatment planning, case management, psychiatric services, therapy, crisis services, and rehabilitation-focused supports delivered face-to-face

Policy Changes and Effective Dates

2025-06-20Interim reviewLatest

State updates removed annual limitations for Peer Support Services and Psychoeducation; added ACT services and LOCUS criteria information; Optum approval noted 2025-05-20 and state approval 2025-06-20.

2025-02-18Annual review

Psychoeducation services were added effective 2025-01-01 and state recommendations clarified the Peer Support Specialist role, specified that face-to-face services include audiovisual telecommunications, and added targeted case manager education and training requirements.

Policy Summary

PayerOptum

PolicyKentucky Medicaid Supplemental Clinical Criteria — Behavioral Health

Policy CodePolicy BH803KY012025

Change TypeService additions, clarifications, and limits removed

Effective DateJan 1, 2025

Last ReviewJun 20, 2025

Next Review DateN/A

Key ActionDocument and retain treatment-plan reviews and required service contacts to support authorization and billing (e.g., 4 TCM contacts/month, age-specific PRTF review intervals).

SourceLink

On This Page

Documentation required for continued authorization

A unit equals one month; at least 4 service contacts per month are required, with two face-to-face contacts with the client; other contacts may be face-to-face or telephone.

>=4 contacts/month; >=2 face-to-face

Same monthly unit/contact structure applies to SUD targeted case management

TCM with co-occurring chronic complex physical health: A unit equals one month; at least 5 service contacts per month are required, with three face-to-face contacts; documentation of the chronic/complex physical health diagnosis signed and dated by a qualified medical professional must be present in the record.>=5 contacts/month; >=3 face-to-face

Applies to members with co-occurring chronic/complex physical health conditions per state reimbursement regulations

Member is at risk of out-of-home placement or inpatient mental health treatment

DSM-5 diagnoses: Member diagnosed with schizophrenia spectrum, bipolar, depressive, or PTSD (trauma/stressor-related) per DSM-5

Chronicity or hospitalization: Clinically significant symptoms persisted >=2 years OR hospitalized for mental illness more than once in past 2 years

Functional impairment: Member is significantly impaired in social or occupational functioning

Member is not between ages 21 and 64 while receiving services in an institution for mental disease or an inmate of a public institution

Current impairment: Member is currently impaired in social or occupational functioning

Documentation requirement: Documentation of chronic/complex physical health diagnosis signed and dated by a qualified medical professional must be in the medical record

Level I PRTF: re-evaluate and review treatment plan at least every 30 days; reviews must include dated signatures of appropriate staff and parent/guardian when present, assessment of progress, revisions, and statement of justification for level of services
Level II PRTF: initial review by 3rd business day post-admission with dated signatures, progress assessment, and justification; follow-up reviews every 14 days for ages 4–5 and every 30 days for ages 6–22 as specified
Incomplete or unsigned reviews risk denial of continued stay authorization

Billing Rule

Targeted Case Management Billing Unit

Targeted Case Management (TCM) billing is on a monthly unit basis. To bill one monthly unit, providers must document and meet the minimum contact and documentation criteria.

Unit of service = one month
A billable month requires meeting the minimum contact and documentation criteria described in the policy; each unit must be supported in the client record

Billing Rule

Billing Requires Meeting Contact and Documentation Criteria

Billing for Targeted Case Management requires meeting the contact and documentation criteria: at least four service contacts per billed month, with required face-to-face contacts and documented assessments, care plan development/revision, monitoring, and quarterly face-to-face monitoring as specified. Failure to document the minimum contacts or required elements risks noncompliance and denial.

Adults with SMI: at least 4 contacts/month (minimum 2 face-to-face, which may include audiovisual telecommunications)
Children with SED: at least 4 contacts/month (minimum 2 face-to-face: one with the child and one with family/parent/guardian), other contacts may be by phone or on behalf of the child
Assessments/reassessments at least annually (or more often as needed); monitoring no less than once every three months and face-to-face

Prior Authorization

Potential Prior Authorization Impacts from Policy Changes

Policy changes (for example: addition of psychoeducation, removal of prior annual limits) may affect prior authorization decisions and billing practices. Providers should review updated policy provisions and state regulations when submitting authorization requests.

Psychoeducation was added effective 01/01/2025 and is included in per diem for specified levels of care
State updates removed annual limitations for Peer Support Services and Psychoeducation (see revision history) — confirm current limits when seeking authorization
Changes to covered service definitions may alter prior authorization requirements or documentation expectations

Billing Rule

TCM Contact and Minimum Contact Requirements

TCM contact requirements and minimum contacts: a monthly TCM unit requires at least four service contacts; two must be face-to-face for adults (one of the two face-to-face contacts for children must be with the child and the other with family). Document each contact in the client record. Exceeding caseload limits or failing to meet minimum contacts risks noncompliance.

Minimum = 4 contacts/month to bill one TCM unit
Adults with SMI: minimum 2 face-to-face (face-to-face may include audiovisual)
Children with SED: 2 face-to-face contacts — at least one with the child and one with family/parent/custodian
Targeted case manager maximum caseload = 25 unique clients (excludes certain crisis services)

Note

Unspecified Provider Actions — Consult Policy and Regulations

(Provider action placeholder) Ensure provider actions align with the full policy and state administrative regulations; if an item is not explicitly stated in this section, consult the complete policy and applicable Kentucky Administrative Regulations for requirements and billing rules.

Consult 907 KAR and 908 KAR references in policy References section for regulatory specifics
When in doubt, contact the payer for clarification on coverage or billing interpretation

Documentation Required

Psychoeducation Documentation and Treatment Plan Note

Psychoeducation must be provided consistent with a person-centered, individualized treatment plan; the rationale and indication for psychoeducation must be documented in the treatment plan and clinical record. Psychoeducation is an adjunct to clinical care and documentation should reflect session content, goals, and alignment to the treatment plan.

Rationale for psychoeducation must appear in the individualized treatment plan and be documented in the client record
Document number of sessions, session duration, group size (optimal group size noted as 8), and essential components covered

Billing Rule

Psychoeducation Billing Constraint

Psychoeducation billing constraint: psychoeducation is included in the per diem for day treatment, TRP, IOP, PHP, and residential services and must not be billed separately on the same day; do not unbundle services that are included in the appropriate level-of-care per diem.

Psychoeducation is part of the per diem for day treatment, TRP, IOP, PHP, and residential — never billed separately on the same day
Do not unbundle services that are bundled in the level-of-care per diem

Documentation Required

Reference Kentucky Administrative Regulations — Documentation and Service Alignment

Providers must align documentation and service delivery with Kentucky Administrative Regulations referenced in this policy (examples: PRTF rules, Targeted Case Management, Peer Support Services, Day Treatment). Maintain dated signatures, supervision records, assessments, and treatment plan reviews as required by state rules.

See cited KARs: 907 KAR 9:005 (PRTF), 907 KAR 15:005/015/040/065 (TCM, Comprehensive Community Support, Day Treatment), 908 KAR 2:220 (Peer Support)
Keep supervision documentation for peer support and TCM per KAR requirements (frequency, signed records)
Ensure treatment plan reviews and signatures follow KAR timelines to support continued authorization

Peer support rolePeer support specialists may provide support services under supervision as part of the ACT team

PRTF Level II young child review interval (age 4-5: 14 days)

Interval (age 4-5)For Level II PRTF members aged 4–5: complete review of treatment plan at least once every 14 days after the initial review

Review contentEach 14-day review must include dated signatures of appropriate staff (and parent/guardian/legal custodian), assessment of progress toward each treatment goal with revisions, and justification for continued services and suitability for less-restrictive environment

Initial review timingLevel II PRTF initial review must be completed by no later than the third business day following admission

Minimum monthly service contacts for TCM (standard and co-occurring physical health variants)

Standard TCMOne monthly unit requires at least 4 service contacts per month; two of the contacts must be face-to-face (includes audiovisual telecommunication) for adults with SMI

Children (SED)For children with SED: at least 4 contacts/month with two face-to-face contacts — one with the child and one with the family/parent/custodial person

Co-occurring chronic physical healthFor members with co-occurring chronic complex physical health issues: one monthly unit requires at least 5 contacts/month with three face-to-face contacts

See Level I vs Level II distinctions and review frequencies

Level I LOC: Requires long-term inpatient psychiatric care or crisis stabilization most appropriately provided in a PRTF and requires continuous Level I services; re-evaluation and treatment plan review at least every 30 days.30 days

Includes dated signatures and justification in reviews

Level II LOC: Child with severe emotional disability and additional complicating factors (aggression, intellectual disability, sexually acting out, or developmental disability) requiring Level II care; initial review by third business day and age-specific follow-up intervals (14 days for ages 4-5; 30 days for ages 6-22).age-specific intervals

Documentation required for continued authorization

Level II PRTF specific level-of-care criteria

Level II-specific continued stay criteria:

Initial review requirement: Level II PRTF must complete an initial review by the third business day following admission including dated signatures, assessment of progress toward each treatment goal with revisions, and justification for continued level of services and suitability for a less-restrictive environment.initial review by 3rd business day

Documentation and signatures required

Young child review interval: For members aged 4-5, review treatment plan at least once every 14 days after the initial review, including dated signatures and progress assessment.every 14 days

Supports authorization for continued Level II care

Older child/adolescent review interval: For members aged 6-22, review treatment plan at least once every 30 days after the initial review, including dated signatures and progress assessment.every 30 days

Supports authorization for continued Level II care

Targeted Case Management (SMI/SED) level-of-care criteria

Level-of-care criteria for TCM (SMI/SED):

TCM (SMI/SED) LOC criteria: Member diagnosed with SMI or child with SED per KRS 200.503(3); not an inmate or IMD resident aged 21-64; needs assistance accessing community supports; involvement with child welfare/criminal justice or at risk of out-of-home placement or inpatient treatment; persistent disability or multiple hospitalizations indicating significant functional impairment.N/A

Meets level for community-based TCM services

Therapeutic Rehabilitation (day program / community-based) level-of-care criteria

Level-of-care criteria for Therapeutic Rehabilitation (day program / community-based):

Therapeutic Rehabilitation LOC: Member requires a therapeutic program less than 24-hour/day but more than outpatient counseling to develop or restore interpersonal, daily living, and personal adjustment skills; services are goal-oriented and person-centered with regular treatment plan review (at least every three months).treatment plan review every 3 months

Services may be individual or group and include weekly summary notes and documentation

Targeted Case Management (community-based) level-of-care criteria

Level-of-care criteria for community-based TCM:

Community-based TCM LOC: Units are monthly with minimum contact requirements (standard: 4 contacts/month; co-occurring physical health: 5 contacts/month) and require comprehensive assessment, individualized care plan, monitoring, periodic reassessments, and documentation to support ongoing need.>=4 or >=5 contacts/month

Face-to-face contact minimums vary by population

LOCUS referenced for level-of-care determination

Reference guidance for level-of-care determination:

LOCUS reference: Apply the Level of Care Utilization System (LOCUS) as a supplemental tool for level-of-care determination where indicated by program rules and state guidance.N/A

LOCUS referenced in policy references

Supervision and documentation requirements apply

Psychoeducation modality: Psychoeducation is a brief, structured intervention delivered individually or in groups (5-24 sessions, typically 40-60 minutes) that teaches diagnosis, treatment, relapse prevention, coping and medication management; when part of higher-level programs it is included in per diem and must be reflected in the treatment plan.5-24 sessions; 40-60 minutes

Optimum group size ~8

Therapeutic Rehabilitation modality

Therapeutic Rehabilitation modality description:

Therapeutic Rehabilitation modality: Services may be provided individually or in groups and include individual, group, family therapies and collateral services focusing on daily living skills, symptom self-monitoring, emotional regulation, crisis coping, and interpersonal skills to restore functional level.N/A

Treatment plans reviewed at least every three months; weekly summary notes required

Targeted Case Management modality

Targeted Case Management modality and core components:

TCM modality: Includes comprehensive assessment, individualized care plan, referrals, monitoring and follow-up; delivered monthly with defined minimum contacts and face-to-face monitoring at least every three months and assessments at least annually.monthly unit; >=4 or >=5 contacts

Documentation must substantiate services provided

Assertive Community Treatment (ACT), Peer Support, TCM, Psychoeducation grouped modality

Grouped modalities commonly used in community-based behavioral health programs:

ACT, Peer Support, TCM, Psychoeducation group: Assertive Community Treatment, Peer Support Services, Targeted Case Management, and Psychoeducation are program modalities that should be coordinated within individualized treatment plans, documented appropriately, and delivered per state training, supervision, and contact requirements.varies by modality

Refer to specific modality sections for detailed requirements

Psychoeducation sessions usually last 40–60 minutes and are mostly held at weekly intervals

Session count (psychoeducation)Number of psychoeducation sessions usually varies from 5 to 24

Targeted Case Management unit requirements — 4 contacts per monthly unit

Unit contact requirementA billable TCM monthly unit requires at least 4 service contacts per month

Face-to-face minimumFor adults with SMI, two of the four contacts must be face-to-face (includes audiovisual telecommunication)

Alternate contactsThe other contacts may be face-to-face or by telephone with or on behalf of the client

Targeted Case Management (varies by population) — 4 or 5 contacts depending on population

Standard populationsStandard TCM: one monthly unit requires ≥4 contacts/month (two face-to-face) — applies to adults with SMI, children with SED, and SUD TCM

Co-occurring physical healthTCM for co-occurring MH/SUD with chronic complex physical health issues: one monthly unit requires ≥5 contacts/month (three face-to-face)

Children under 18 with co-occurring conditionsFor children under 18 with SED and co-occurring chronic physical health: contact distribution includes two face-to-face with the child, two face-to-face with parent/guardian, plus one additional face-to-face or telephone contact

Targeted Case Manager caseload — maximum 25 unique clients

Maximum caseloadTargeted Case Manager caseload shall not exceed 25 unique clients receiving any service (excluding mobile crisis, crisis intervention, or screenings)

Training and supervisionTargeted case managers must complete department-approved training within six months of employment and continuing education every 3 years; supervision requirements vary by population served

Scope limitationA targeted case manager shall only provide TCM to the population for which they meet educational, experiential, and training requirements and shall not provide other behavioral health services to the same client

Peer Support Services and Psychoeducation — annual limitations removed

Annual limitsAnnual limitations for Peer Support Services and Psychoeducation have been removed (policy update effective 06/20/2025)

Psychoeducation inclusionPsychoeducation is included in per diem rates for day treatment, TRP, IOP, PHP, and residential services and must not be billed separately on the same day

Peer support clarificationState updates clarified Peer Support Specialist roles and that face-to-face services include audiovisual telecommunications

Team requirementsProvided by a multidisciplinary team led by an approved behavioral health services practitioner with minimum staffing and documentation/coordination expectations

LOCUS referenceFor additional clinical criteria, apply the Level of Care Utilization System (LOCUS) as referenced in policy references

Peer Support definition

DefinitionPeer Support: evidence-based nonclinical therapeutic social and emotional support provided by a Peer Support Specialist in structured and scheduled individual or group activities, delivered by persons with lived experience or family members

CertificationPeer Support Specialists must complete state-approved training and eligibility requirements (per 908 KAR regs) and be employed by a Medicaid-enrolled provider or licensed organization

Service integrationPeer support must be coordinated within the individualized treatment plan, be recovery-oriented, person-centered, voluntary, relationship-focused and trauma-informed, and group services must not exceed 8 individuals

Psychoeducation definition

DefinitionPsychoeducation: a direct, planned, structured intervention presenting information to individuals and families about diagnosis, treatment options, relapse prevention, coping skills and recovery strategies

Delivery formatsDelivered individually or in groups; usually 5–24 sessions of 40–60 minutes typically at weekly intervals; included in per diem for higher-level programs

Documentation and billingRationale and indication must be reflected in the individualized treatment plan and documented; psychoeducation included in per diem must not be billed separately on the same day

Targeted Case Management (TCM) definition

DefinitionTargeted Case Management (TCM): services to assist members in gaining access to needed medical, social, educational and other services; billed in monthly units with minimum contact requirements varying by population

Unit structureA unit equals one month; billable unit requires defined minimum number and type of contacts (e.g., ≥4 contacts/month standard; ≥5 for co-occurring chronic physical health)

Provider requirementsTargeted case managers must meet training, experience, and supervision standards and may not exceed caseload limits; supervisors must document supervision

Therapeutic Rehabilitation Program definition

DefinitionTherapeutic Rehabilitation Program (TRP): a rehabilitative service for adults with SMI or children with SED designed to reduce effects of mental disorder and restore functional level through psychiatric rehabilitation techniques delivered individually or in groups

Service focusEmphasis on daily living skills, interpersonal skills, emotional regulation, symptom self-monitoring, crisis coping and personal adjustment

Care levelProvides programs for persons who require less than 24-hour care but more than outpatient counseling; services are goal-oriented and person-centered

LOCUS definition/reference

ReferenceLOCUS: Level of Care Utilization System for Psychiatric and Addiction Services (American Association of Community Psychiatry, AACP)

UseReferenced as an additional clinical tool to apply LOCUS criteria for level-of-care determinations in policy

Source citationAACP (2020). LOCUS Demo Version 20 — cited in policy references

State regulatory references (Kentucky Administrative Regulations)

Primary sourceKentucky Administrative Regulations cited throughout policy (e.g., 907 KAR and 908 KAR citations) for ACT, PRTF, TCM, Peer Support and other services

ExamplesCited regs include: 907 KAR 15:020 (ACT/CCS), 907 KAR 9:005 (PRTF), 908 KAR 2:220/2:230/2:240 (Peer Support), and targeted case management regs (907 KAR 15:005, 15:040, 15:065)

Provider obligationProviders must align service delivery and documentation with applicable Kentucky Administrative Regulations referenced in the policy

Version 4 annual review recorded (summary of changes not detailed in source).

2023-01-01Annual review

Version 3 summary of changes recorded (details not provided in source).

2022-01-01Annual review

Version 2 summary of changes recorded (details not provided in source).

2021-01-01Initial publication

Version 1 published (summary of changes recorded as Version 1).