Currentpriority healthPolicy N/A

Partial Hospitalization Program (PHP)

Defines coverage, authorization, coding, and documentation requirements for Partial Hospitalization Programs for mental health/psychiatric care for Priority Health members. Applies to providers submitting claims for PHP services.

Policy Summary

Payerpriority health

PolicyPartial Hospitalization Program (PHP)

Policy CodePolicy N/A

Change TypeOperational updatescoding and billing clarifications

Effective DateOct 7, 2024

Next Review DateFeb 1, 2025

Key ActionRequest and obtain authorization prior to sending a member to PHP and ensure member meets InterQual® Behavioral Health medical necessity criteria.

SourceLink

POLICY UPDATE CHANGES

Added revenue codes 0912 and 0913.

Added revenue code 0911.

Added 'Frequency' information indicating Rev code 0912 is per day and multiple units per day are not appropriate.

Added 'Disclaimer' section.

Added Bill Type Table.

Authorization requiredprior authorization policy

InterQual® BHmedical necessity standard

POS 52example place of service code

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Coverage and Medical Necessity

Medical Necessity / Authorization Criteria

Covered when ALL of the following are met

PHP coverage criteria: Member has a primary mental health/psychiatric diagnosis; Member meets InterQual® Behavioral Health medical necessity criteria for partial hospitalization; Authorization requested and obtained prior to program admission; Treatment goals identified.

Uses InterQual BH criteria; authorization required prior to admission.

Programs that are primarily social, recreational, or diversionary in nature are excluded from Partial Hospitalization Program (PHP) coverage. Such programs do not meet the definition of PHP because they lack the structured, intensive clinical treatment components required for partial hospitalization.

Services provided by programs that are primarily social, recreational, or diversionary are not considered PHP services and therefore do not meet PHP medical necessity criteria. Claims for these services should not be billed or authorized as PHP.

Place of Service, Revenue, and Condition Codes

Place of Servicemixed

POS 52

Psychiatric Facility Partial Hospitalization

Example Revenue CodesRevenue

0250	Drugs and Biologicals
043X	Occupational Therapy
0900	Behavioral Health Treatment/Services
0904	Activity Therapy
0910	Psychiatric/Psychological Services
0911	Rehabilitation
0912	Psychiatric Partial Hospitalization (less intensive)
0913	Psychiatric Partial Hospitalization (intensive)
0914	Individual Therapy
0915	Group Therapy

1–10 of 13

1/2

Condition Codesmixed

Condition code 41

Indicates claim for partial hospitalization services for hospitals and CAHs

Per-day billing for Rev code 0912

Billing ruleRev code 0912 is considered per day; billing more than one unit per day is not appropriate.

Applicable code0912 — Psychiatric Partial Hospitalization (less intensive)

Frequency interpretationMaximum of 1 unit billed per calendar day for this revenue code.

Authorization, Documentation, and Billing Responsibilities

Prior Authorization

Prior authorization and medical necessity

Authorization must be obtained before admitting a member to a Partial Hospitalization Program (PHP). Members must meet InterQual® Behavioral Health medical necessity criteria for partial hospitalization and have a primary mental health/psychiatric diagnosis with identified treatment goals.

Request authorization prior to sending a member to PHP.

Note

Medical necessity reference #91447

Reference Medical Necessity policy #91447 and the Provider Manual for details on partial hospitalization authorization processes and requirements.

Documentation Required

Program Overview

Partial hospitalization is an intensive, organized treatment program intended for patients who would otherwise require inpatient psychiatric care. It is more intensive than outpatient day treatment or psychosocial rehabilitation and must provide structured clinical treatment rather than primarily social or recreational activities.

Key Terms

Partial hospitalization — definition and distinguishing features

DefinitionPartial hospitalization is a distinct and organized intensive treatment program for patients who would otherwise require inpatient psychiatric care; it is more intense than outpatient day treatment or psychosocial rehabilitation.

Exclusion — program typePrograms providing primarily social, recreational, or diversionary activities are not considered partial hospitalization and are excluded from PHP coverage.

Clinical focusPrimary diagnosis should be a mental health/psychiatric diagnosis and treatment goals must be identified.

Authorization requirementAuthorization must be requested and obtained prior to admission to a PHP.

Partial Hospitalization Program (PHP) Level of Care

Partial Hospitalization Program (PHP) — Level of Care Criteria

Admission to PHP: Patient would otherwise require inpatient psychiatric care and meets InterQual® Behavioral Health criteria for partial hospitalization; primary diagnosis is a mental health/psychiatric diagnosis; authorization obtained prior to admission; treatment goals identified.

InterQual BH criteria required per policy.

Continued stay: Ongoing need for intensive services that cannot be met in lower levels of care; documentation of progress toward treatment goals and continued medical necessity per InterQual; authorization maintained as required.

Policy states no specific time limits but continued authorization required.

Discharge when patient no longer requires PHP intensity, meets lower level of care, or treatment goals are met.

Multidisciplinary Services and Treatments

PHP multidisciplinary services

Typical PHP services: Individual therapy, group therapy, family therapy, activity therapy, behavioral health testing, education/training, occupational therapy, medications/drugs as part of treatment.

Reflects revenue codes and examples listed in policy.

Visit and Unit Limits

Rev code 0912 (Psychiatric Partial Hospitalization - less intensive) — 1 unit and frequency rule

Units allowed1 unit per day for Rev code 0912.

Code description0912 — Psychiatric Partial Hospitalization (less intensive)

Billing guidanceDo not bill multiple units of 0912 in the same day; treat the service as a per‑day revenue code.

Prior auth tie-inAuthorization is required prior to sending a member to PHP and InterQual® Behavioral Health criteria must be met.