Currentpartners_health_managementPolicy N/A

In Home Therapy Services (IHTS) - Coverage Criteria

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Defines coverage, eligibility, utilization management, staffing, and documentation requirements for In Home Therapy Services (IHTS) for children and adolescents with complex psychosocial needs; applies to Providers seeking Partners Health Management authorization and reimbursement for IHTS in North Carolina.

Policy Summary

Payerpartners_health_management

PolicyIn Home Therapy Services (IHTS) - Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateApr 1, 2023

Next Review DateN/A

Key ActionObtain prior authorization for IHTS before initiating services; initial authorization up to six months with re-authorization every six months.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1 unit = 1 weekbilling unit definition

≥2 hrs/wkminimum billed service time per unit

24 unitsaverage course (up to 6 months)

age 3-21eligible beneficiary age range

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Currentpartners_health_managementPolicy N/A

In Home Therapy Services (IHTS) - Coverage Criteria

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Policy Summary

Payerpartners_health_management

PolicyIn Home Therapy Services (IHTS) - Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateApr 1, 2023

Next Review DateN/A

Key ActionObtain prior authorization for IHTS before initiating services; initial authorization up to six months with re-authorization every six months.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1 unit = 1 weekbilling unit definition

≥2 hrs/wkminimum billed service time per unit

24 unitsaverage course (up to 6 months)

age 3-21eligible beneficiary age range

Coverage and Medical Necessity Criteria

Entrance (Initial) Criteria

Covered when ALL of the following are met

Entrance Criteria: Beneficiary age 3-20 with a mental health or substance use disorder diagnosis (per DSM-5) other than a sole diagnosis of intellectual and developmental disability; AND based on a current comprehensive clinical assessment, IHTS is indicated and traditional office-based outpatient services were considered or previously attempted and were inappropriate or ineffective; AND the clinical assessment identifies need for linkage/coordination with other service systems or community resources to prevent family disruption or need for more intensive levels of care; AND symptoms/behaviors at home, school, or community are moderate to severe and require intensive, coordinated clinical interventions; AND evidence of problems in at least two major life domains (examples: housing safety/stability, education/school issues, physical health care linkage/access, involvement with DSS, juvenile justice/legal system, or Exceptional Children's Program); AND the consumer does not present with an imminent risk of BOTH out-of-home placement and a history of multiple crisis events within the last 6 months; AND there is no evidence that alternative interventions would be equally or more effective based on North Carolina community practice standards (e.g., AACAP, APA, ASAM).age 3-20

Continued Service Criteria

Eligible to continue if the PCP goals are not yet achieved and one of the following applies

Continued Service: The beneficiary has achieved current PCP goals and additional/new goals are indicated; OR is making satisfactory progress and documentation supports that continuation of IHTS will be effective in addressing PCP goals; OR is making some progress but specific PCP interventions need modification to attain greater gains consistent with premorbid functioning; OR fails to make progress or demonstrates regression, prompting reassessment of diagnosis, revision of interventions, and consideration of alternative or additional services.service time-limited, typically ≤ 6 months

Discharge Criteria

Discharge when ANY of the following apply

Discharge: The individual has made significant progress toward rehabilitation goals and discharge to basic, office-based therapy with the same licensed therapist is indicated; OR the individual requires a more intensive level of care or service (submit discharge Service Authorization Request at time of discharge).

Service is not billed on dates when the consumer is receiving inpatient hospitalization services. IHTS may facilitate coordination of discharge planning if an admission occurs, but billing for IHTS is excluded on inpatient dates of service.

In Lieu of Services are not included in the Medicaid state plan and are provided only when they are expected to be a cost-effective alternative to state plan services and produce outcomes that are as good as or better than the state plan service. In Lieu of Services may be provided to individuals participating in NC Innovations or other home and community-based waiver programs (for example CAP/C or CAP/DA) only when the alternative services are not otherwise available through those programs.

IHTS is not appropriate when traditional office-based outpatient treatment services have not been considered or previously attempted and found inappropriate or ineffective; IHTS is intended for situations where outpatient care was insufficient.

IHTS should not be used when there is evidence that alternative interventions would be equally or more effective based on North Carolina community practice standards (for example guidelines from the American Academy of Child and Adolescent Psychiatry, American Psychiatric Association, or the American Society of Addiction Medicine).

Billing, Units, and Codes

IHTS codesHCPCSCovered

H2022 HE	IHTS-related code (as listed)
H2022 TS	IHTS-related code (as listed)
U5	Modifier or rate designation (as listed)

inv-07: Minimum weekly service time — >= 2 hours per week

Minimum weekly service time>= 2 hours per week (provider must deliver at least 2 hours of combined therapy and care coordination during the week Sunday–Saturday)

Billing frequencyOnly one IHTS unit may be billed per week (1 unit = 1 week)

Unit purposePer‑diem event representing combined therapy and coordination time for that week

Authorization, Documentation, and Provider Requirements

Prior Authorization

Obtain prior authorization (initial ≤ 6 months)

Prior authorization is required for In Home Therapy Services (IHTS). Initial authorization may not exceed six months; re-authorization is required every six months.

Step Therapy

Confirm outpatient treatment was attempted/considered

IHTS is indicated only after traditional office-based outpatient treatment services were considered or previously attempted and found inappropriate or ineffective; ensure documentation of prior outpatient consideration or attempts.

Documentation Required

Document each contact per APSM 45-2

Program Background

In-Home Therapy Services (IHTS) is a time-limited, in-home combination of evidence-based therapy and care coordination for children and adolescents with complex psychosocial situations and multisystem involvement. It focuses on family-systems work and coordination with other service systems to prevent family disruption and the need for more intensive levels of care.

IHTS targets children and adolescents (approximately ages 3–21) with Serious Emotional Disturbance (SED) or Serious Mental Illness (SMI) whose symptoms are moderate to severe and who require intensive, coordinated interventions across settings. The service is intended for beneficiaries whose needs are not adequately met by traditional outpatient care and where the clinical assessment identifies the need for linkage/coordination with other systems (for example housing, education, physical health, DSS, juvenile justice, or Exceptional Children's Program) to address problems in at least two major life domains.

Definitions and Target Population

inv-14: In Home Therapy Services (IHTS) — definition of the service

DefinitionA combination of evidence‑based therapy services and coordination of care interventions provided in the home (or community) setting for youth with complex psychosocial needs that traditional outpatient services cannot adequately address in a time‑limited fashion.

Service componentsIntegrated delivery of evidence‑based therapeutic interventions plus active coordination/linkage with schools, juvenile justice, child protective services, and other systems as needed.

GoalPrevent escalation to more restrictive levels of care and intensively engage families to improve outcomes.

inv-15: Target population — children and adolescents (ages 3-21) with SED or SMI, family systems issues, multisystem involvement

Age rangeChildren and adolescents, ages 3–21

Diagnoses

Level of Care / Setting Criteria

In-Home / Community-based (Rehabilitative)

Criteria for the In-Home / Community-based (Rehabilitative) level of care

Level of Care Requirements: Service is delivered in the home or community for children/adolescents (age 3-21) with complex psychosocial needs and multisystem involvement where traditional outpatient services are insufficient; targeted family-systems work is required to prevent escalation to more restrictive levels of care; team includes at least two staff (licensed professional providing therapy and oversight; coordination by QP/AP as appropriate); licensed therapist caseload up to 12 IHTS consumers; agency must provide telephonic crisis response and the service is time-limited, generally ≤ 6 months.

Therapeutic Approaches Included

Evidence-based therapy and care coordination

Required modalities and staffing for IHTS

Modality Requirements: Therapy is delivered by a licensed professional (LP) responsible for therapy provision and oversight; coordination functions may be performed by a Qualified Professional (QP) or Assistant Professional (AP) with Family Partner training; selected evidence-based treatment modality training required for LP as specified by the model developer or qualified trainer (trauma-focused treatment includes participation in a yearlong learning collaborative); LP, QP, and AP must complete mandatory state trainings, crisis response training, crisis plan development training, and at least 24 hours of relevant training within the past 10 years, plus annual follow-up/continuing education (minimum 10 hours annually for the chosen modality).

Units, Frequency, and Duration Limits

inv-18: IHTS unit (minimum 2 hours/week) — unit definition and minimum service per unit

Unit definition1 IHTS unit = per‑diem event representing services for one week (billing period Sunday–Saturday)

Minimum service per unitAt least 2 hours of combined therapy and coordination must be provided during the week to bill 1 unit

Maximum units per weekOnly one unit may be billed per week

Expected courseAverage consumer receives service up to six months (expected utilization ≈ 24 units)