Coverage Policies

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Note: For Arkansas State or Public School employees, services subject to pre-authorization are managed by Active Health Management, as noted in their Summary Plan Description.

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If not specified in a QualChoice coverage policy (Benefit Interpretation), QualChoice follows care guidelines published by MCG Health.

QualChoice reserves the right to alter, amend, change or supplement medical policies as needed. QualChoice reviews and authorizes services and substances. CPT and HCPCS codes are listed as a convenience and any absent, new or changed codes do not alter the intent of the policy.

INDEX:
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

Effective Date: 12/11/2008 Title: CHI Residential Treatment Program
Revision Date: 09/01/2014 Document: BI208:00
CPT Code(s): None
Public Statement

 

Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1)    For members of the Catholic Health Initiatives program, care is covered for admission into, and continued care in, a residential facility for treatment of chemical dependency subject to a requirement for pre-authorization.  

2)    A residential treatment facility for chemical dependency is a facility that offers treatment for patients that require close monitoring of their behavioral and clinical activities related to their chemical dependency or addiction to drugs or alcohol. These programs are comprehensive and address potential withdrawal symptoms/behaviors and incorporate psychotherapeutic treatments and education through a multidisciplinary team approach.

3)    A residential treatment facility for chemical dependency is a 24-hour facility that is not a hospital. Residential treatment facilities for chemical dependency are not for "providing housing", custodial care, a wilderness center training camp or any other structured environment whose use is simply to change the person’s environment,.

4)    Most chemical dependency treatment facilities provide limited direct MD or Ph.D. patient care.


Medical Statement

 

1)    ADULT: Residential Treatment of an adult requires pre-authorization. The criteria for pre-authorization are:

a)    The care plan submitted must be individualized and not consist of a standard, pre-established number of days; AND

b)    A residential treatment facility must be the lowest level of care where treatment can safely and effectively be provided given the severity of the individual’s condition; AND

c)    The provider must be able to document that the individual has a history of alcohol/substance dependence but is mentally competent and cognitively stable enough to benefit from admission to the inpatient program at this point in time. Individual days during any part of the stay where the patient does not meet this criterion cannot be certified as medically necessary; AND

d)    The patient exhibits a pattern of severe alcohol and/or drug abuse as evidenced by continual inability to maintain abstinence and recovery despite recent (i.e., the past 3 months), appropriate, professional outpatient intervention; AND

e)    One of the following applies:

i)     The patient is residing in a severely dysfunctional living environment which would undermine effective outpatient treatment; OR

ii)    For individuals with a history of repeated relapses and treatment history involving multiple treatment attempts, there must be evidence of a restorative potential for the proposed admission – especially, evidence of the patients previous efforts at cooperation with the therapeutic regimen; OR

iii)   There is evidence for, or a clear and reasonable inference of, serious imminent physical harm to self or others directly attributable to the continued abuse of substances which would prohibit treatment in an outpatient setting.

2)    CHILD OR ADOLESCENT:    Admission of a child or adolescent requires pre-authorization. Admission criteria include the above criteria AND:

a)    The patient’s current living environment does not provide support for and access to therapeutic services necessary for recovery; AND

b)    The patient’s individual treatment plan must include at least weekly family involvement or identified valid reasons why such a plan is not clinically appropriate.

3)    CONTINUED STAY:

a)    In addition to meeting all of the admission criteria on a daily, continuing basis, there must be documentation at least three times per week supporting the need for continued inpatient treatment. Progress notes 3 times per week should document the providers’ treatment and the patient’s response to treatment.

i)     The treatment maneuvers addressing the problems that created a need for admission and the results of those treatment efforts; AND

ii)    If additional problems that justify admission/continued stay arise, those problems should be documented, there should be a problem-directed treatment plan and notes reflecting treatment for the newly identified problem and the results of that treatment; AND

iii)   The records must reflect clear and reasonable evidence that the patient’s re-entry into the community would result in an exacerbation of the illness to a degree requiring inpatient level of care; AND

iv)   If the patient is a child or adolescent, the record will document at least weekly family involvement in therapy with notation about the results of that involvement, or identified valid reasons why such treatment was not possible.

b)    Every admission will be reviewed at least every two weeks. Continuation of the pre-authorization will be based on meeting admission criteria as outlined above, and on a commentary about how the providers and patient are meeting or planning to meet the following criteria:

i)     Adherence of the patient to the treatment plan or to some negotiated acceptable modification of the treatment plan; AND

ii)    Improvement in the patient’s status or prognosis; AND

iii)   (Especially for children and adolescents) evidence of change in the discharge environment.


Limits

 

1)    Residential treatment is not covered for the use of foster homes or halfway houses.

2)    Residential treatment is not covered for Wilderness Center training.

3)    No benefits are available for custodial care, situation or environmental change.


Application to Products

1)     This policy applies to all Catholic Health Initiative (CHI) enrollees. Such enrollees can be identified by the appearance of the CHI logo on their ID cards, and by the indication that they are in a group numbered 00027030-00027168.

2)     Residential care is not covered under any other plan administered by QualChoice.


Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.
This policy has recently been updated. Please use the index above or enter policy title in search bar for the latest version.