Health Share of Oregon Pathways Regional Practice Guidelines

Regional Behavioral Health Guidelines for Clackamas, Multnomah and Washington Counties

A Manual for Utilization Review Staff and Health Share of Oregon Providers

Revised: November 15, 2018 Effective January 1, 2019 Page 1 of 126 Table of Contents Section/Practice Guideline Page Introduction 4 Practice Guidelines – Values and Principles 5-6 Medical Necessity Criteria 7 List of Services Requiring Self-Authorized Service Notification 8 List of Services Requiring Prior Authorization 9

Mental Health and Substance Use Disorder Practice Guidelines Mental Health Practice Guidelines 10-85 Acute Inpatient 10-12 Community Based Intensive Treatment (CBIT) / Intercept- Youth 13-14 Enhanced Community Based Intensive Treatment (ECBIT) - Youth 15-17 Crisis Stabilization Services- Youth 18-20 Dialectical Behavior Therapy (DBT) 21-23 Eating Disorder Treatment 24-32  Partial Hospitalization (IOP) Services 24-26  Residential Treatment 26-28  Inpatient Hospitalization Services 29-32 Electroconvulsive Therapy 33-34 Mental Health Outpatient Services – Level A – D: Youth and Family 35-47  Mental Health Outpatient Services – Level A: Youth and Family 36-37  Mental Health Outpatient Services – Level B: Youth and Family 38-39  Mental Health Outpatient Services – Level C: Youth and Family 40-41  Mental Health Outpatient Services – Level D: Early Childhood (ages 0-5) 42-44  Mental Health Outpatient Services – Level D: Home Based Stabilization Youth and Family (ages 6-17) 45-47 Mental Health Outpatient Services – Level A – D: Adult 48-65  Mental Health Outpatient Services – MRDD/IDD or Medication Only -Adult 49  Mental Health Outpatient Services – Level A - Adult 50-51  Mental Health Outpatient Services – Level B - Adult 51-52

Revised: November 15, 2018 Effective January 1, 2019 Page 2 of 126  Mental Health Outpatient Services – Level B SPMI – Adult 53-55  Mental Health Outpatient Services – Level C - Adult 55-57  Mental Health Outpatient Services – Level C SPMI – Adult 58-60  Mental Health Outpatient Services – Level D: Adult Intensive Case Management (ICM) or Transition Age 61-65 Youth (TAY) Mental Health Intensive Outpatient 66-67 Mental Health Partial Hospitalization 68-69 Psychiatric Day Treatment Services – Youth 70-71 Psychiatric Residential Treatment Services – Youth 72-74 Psychological Testing 75-77 Respite Services – Youth 78-79 Respite Services – Adult 80-81 Subacute Services – Youth 82-85

Substance Use Disorder Practice Guidelines 85-126 Substance Use Disorder Outpatient – ASAM Levels 1.0, 2.1, and 2.5: Youth 86-90 Substance Use Disorder Outpatient– ASAM Levels 1.0, 2.1, and 2.5: Adult 91-97 Medication Assisted Treatment 98-100 Substance Use Disorder Residential – ASAM Levels 3.1, 3.3, and 3.5 101-107 Dual Diagnosis Residential Treatment – ASAM Level 3.5: Youth 108-111 Dual Diagnosis Residential Treatment – ASAM Level 3.5: Adult 112-115 Substance Use Disorder High Intensity Medically Monitored Residential – ASAM Level 3.7: Adult 116-118 Clinically Managed Withdrawal Management/ Detox – ASAM Level 3.2: Youth and Adult 119-120 Medically Monitored Withdrawal Management/ Detox– ASAM Level 3.7: Youth and Adult 121-123 Transcranial Magnetic Stimulation: Adult 124-126

Revised: November 15, 2018 Effective January 1, 2019 Page 3 of 126 Introduction

Medicaid managed care organizations are required to adopt practice guidelines that are based on valid and reliable clinical evidence, consider the needs of our individuals, and are adopted in consultation with our participating providers. Decisions for utilization management and coverage of services should be consistent with these guidelines.

Health Share of Oregon-along with the Behavioral Health Plan Partners (BHPPs)-Clackamas, Multnomah and Washington County has adopted a definition of medical necessity criteria and a set of practice guidelines as a resource for both providers and our staff. It should be noted that these guidelines are administrative in nature; they are not clinical practice guidelines. Clinical practice guidelines reflect practice standards for the management and treatment of specific conditions .Administrative guidelines describe the criteria for authorization for specific types of service.

The primary purpose of these guidelines is to assist providers in selecting the appropriate level of care for clients, and to inform providers of the criteria used by the BHPPs in authorizing services.

Revised: November 15, 2018 Effective January 1, 2019 Page 4 of 126 Practice Guidelines – Values and Principles Values:

Health Share of Oregon promotes resilience in and recovery of its members. We support a system of care that promotes and sustains a person’s recovery from a mental health condition by identifying and building upon the strengths and competencies within the Individual to assist them in achieving a meaningful life within their community.

Individuals are to be served in the most normative, least restrictive, least intrusive, and most cost-effective level of care appropriate to their diagnosis and current symptoms, degree of impairment, level of functioning, treatment history, individual voice and choice, and extent of family and community supports.

Practice guidelines are intended to assure appropriate and consistent utilization of mental health services and to provide a frame of reference for clinicians in providing services to individuals enrolled in Health Share of Oregon. They provide a best practice approach and are not intended to be definitive or exhaustive.

When multiple providers are involved in the care of our members, it is our expectation that regular coordination and communication occurs between these providers to ensure coordination of care. This could include sharing of service plans, joint session, phone calls or team meetings.

Principles:

1. Treatment planning incorporates the principles of resilience and recovery: . Employs strengths-based assessment . Individualized and person-centered . Promotes access and engagement . Encourages family participation . Supports continuity of care . Empowering . Respects the rights of the individual

Revised: November 15, 2018 Effective January 1, 2019 Page 5 of 126 . Involves individual responsibility and hope in achieving and sustaining recovery . Uses natural supports as the norm rather than the exception

2. Policies governing service delivery are age and gender appropriate, culturally competent, evidence-based and trauma- informed, attend to other factors known to impact individuals’ resilience and recovery, and align with the individual’s readiness for change. With the goal of the individual receiving all services that are clinically indicated. --- Ensuring that individuals have access to services that are clinically indicated.

3. Positive clinical outcomes are more likely when clinicians use evidence based practices or best clinical practices based on a body of research and as established by professional organizations.

4. Treatment interventions should promote resilience and recovery as evidenced by: . Maximized quality of life for individuals and families . Success in work and/or school . Improved mental health status and functioning . Successful social relationships . Meaningful participation in the community

Revised: November 15, 2018 Effective January 1, 2019 Page 6 of 126 Medical Necessity Criteria

All services provided to Oregon Health Plan Medicaid recipients must be medically appropriate and medically necessary. For all services, the individual must have a diagnosis covered by the Oregon Health Plan which is the focus of treatment, and the presenting diagnosis and proposed treatment must qualify as a covered condition-treatment pair on the Prioritized List of Health Services.

Medically appropriate services are those services which are: . Required for prevention, diagnosis or treatment of physical, substance use or mental disorders and which are appropriate and consistent with the diagnosis . Consistent with treating the symptoms of an illness or treatment of a physical, substance use or mental disorder . Appropriate with regard to standards of good practice and generally recognized by the relevant scientific community as effective . Furnished in a manner not primarily intended for the convenience of the individual, the individual’s caregiver, or the provider . Most cost effective of the alternative levels of covered services which can be safely and effectively furnished to the individual

A covered service is considered medically necessary if it will do, or is reasonably expected to do, one or more of the following: . Arrive at a correct diagnosis . Reduce, correct, or ameliorate the physical, substance, mental, developmental, or behavioral effects of a covered condition . Assist the individual to achieve or maintain sufficient functional capacity to perform age-appropriate or developmentally appropriate daily activities, and/or maintain or increase the functional level of the individual . Flexible wraparound services should be considered medically necessary when they are part of a treatment plan.

The determination of medical necessity must be made on an individual basis and must consider the functional capacity of the individual and available research findings, health care practice guidelines, and standards issued by professionally recognized organizations.

Revised: November 15, 2018 Effective January 1, 2019 Page 7 of 126 Self-Authorized Service Notification Required Level A – C Outpatient MH Services – Adult Level B SPMI; and Level C SPMI Outpatient MH Services - Adult Level A – C Outpatient MH Services – Youth Substance Use Disorder Outpatient Services – Adult Substance Use Disorder Outpatient Services - Youth Substance Use Disorder - Formulary Medication Assisted Treatment (Formulary MAT) Substance Use Disorder Clinically Managed Withdrawal Management/ Detox - Initial Authorization Only Substance Use Disorder Medically Monitored Withdrawal Management/ Detox - Initial Authorization Only

*Please note - the list above represents the most frequently accessed service types* **Outpatient services for service types above always requires prior auth from BH Plan Partner when rendered by a provider with a Prior Authorization Fee for Service (PA FFS) contract.**

Revised: November 15, 2018 Effective January 1, 2019 Page 8 of 126 Services that Require Prior Authorizations Acute Inpatient Respite Services – Adult Applied Behavioral Analysis (ABA) Subacute Services – Youth Community Based Intensive Treatment- Youth Substance Use Disorder Day Treatment – Adult Crisis Stabilization Services- Youth Substance Use Disorder Day Treatment – Youth Dialectical Behavior Therapy Substance Use Disorder – Non-Formulary Medication Assisted Treatment (Non-Formulary MAT) Eating Disorder Treatment – Partial Hospitalization and Substance Use Disorder Residential Treatment Intensive Outpatient Eating Disorder Treatment – Residential Treatment Substance Use Disorder/ Dual Diagnosis Residential Treatment- Youth Electroconvulsive Therapy Substance Use Disorder/ Dual Diagnosis Residential Treatment- Adult Enhanced Crisis Stabilization Services - Youth Substance Use Disorder High Intensity Medically Monitored Residential- Adult Level D Early Childhood Outpatient MH Services - Youth Substance Use Disorder Clinically Managed Withdrawal Management/ Detox - Continued Stay Authorizations Level D Home Based Stabilization Outpatient MH Services - Substance Use Disorder Medically Monitored Withdrawal Youth Management/ Detox - Continued Stay Authorizations Level D Transition Age Youth Outpatient MH Services Transcranial Magnetic Stimulation Level D Intensive Case Management MH Services - Adult Subacute Services – Youth Partial Hospitalization Substance Use Disorder Day Treatment – Adult Psychiatric Day Treatment Services – Youth Substance Use Disorder Day Treatment – Youth Psychiatric Residential Treatment Services – Youth Psychological Testing Respite Services – Youth

Revised: November 15, 2018 Effective January 1, 2019 Page 9 of 126 Mental Health Practice Guidelines

Acute Inpatient Service Description Criteria for Authorization Concurrent Review Transition/ Discharge Criteria Criteria Inpatient Utilization Management Guidelines Youth and Adult Mental Health Inpatient protocol for Health Share Members. Refer to the Standardization of Inpatient Mental Health UM Policies and Procedures Acute inpatient psychiatric All Admission Criteria Must At least two of the following are At least one of the following services are intensive, 24 hour be Met: present: must be met: services, occurring in an  Client must have or be  The persistence of psychiatric  Documented treatment appropriately licensed hospital. suspected of having a problems that resulted in the goals and objectives have Services are provided under the covered primary mental admission to a degree that been substantially met supervision of a licensed health disorder covered continues to meet admission  Individual has achieved psychiatrist and are focused on by the Oregon Health Plan criteria symptom or functional reducing immediate risk due to that is the cause of the  The emergence of additional improvement back to dangerousness to self or others, signs and symptoms that problems that meet baseline in resolving issues grave disability, or complicating make consideration of admission criteria that resulted in admission medical conditions (co-occurring hospitalization necessary  A severe reaction to to this level of care with a mental health condition)  The client must be medication or the need for  Meets criteria for a that leave the individual at medically stable and further monitoring and different level of care due significant risk. Treatment is medical causes have been adjustment of dosage that to change in symptoms or highly intensive and is provided ruled out as the source of required 24 hour medical function at this level of care in a secure environment by a the mental or behavioral supervision multidisciplinary team of symptoms  Daily progress notes qualified mental health  Less restrictive levels of document that the client’s professionals. care must have been mental health problem(s) are

explored, including responding to or are likely to Services may include an initial increasing the intensity of assessment, history and physical,

Revised: November 15, 2018 Effective January 1, 2019 Page 10 of 126 individual, group, family and/or outpatient treatment, and respond to the current activity therapies, social skill demonstrated to be less treatment plan development, nutritional care, likely to be effective,  Evidence of active discharge more intrusive, medically appropriate physical planning in collaboration unavailable or too with UR Coordinator and/or health care, and room and board dangerous RAE Care Coordinator  Admission cannot be  Evidence of active treatment * Re-assessment is considered strictly for the purpose of including modification of complete when adequate time temporary housing or due treatment plan where has lapsed from when the to homelessness progress is limited individual arrived intoxicated to  For individuals presenting  No less restrictive level of the ED and verified by a UA, BAL with intoxication due to care that would meet the alcohol, sobering must client’s and public’s need for or self-report and the clinical occur and the individual safety is accessible presentation remains the same must be re-assessed*  The client’s need for after the individual is considered prior to approval for an continued care is not for the sober in the clinical judgment of inpatient stay. primary purpose of medical personnel. A 2PndP UA or  For other substances, if temporary housing or due to BAL is not required by the BHPP the individual meets the homelessness criteria for “a clear and UR staff. reasonable inference of Please Note: This is baseline danger to self or others”, criteria that are being regionally ** Criteria related to individuals admission will be applied by Health Share- presenting with Co-occurring approved. ** symptoms At least one of the following Clackamas County, Multnomah is present: and Washington. Each Behavioral  A clear and reasonable Health Plan Partner (BHPP) may inference of danger to decide to approve someone that self or others. ** is above the baseline criteria  Dangerous assaultive or based on allowable resources other uncontrolled (example: co-occurring member behavior, including admitted by one BHPP because extensive damage to

Revised: November 15, 2018 Effective January 1, 2019 Page 11 of 126 property, not due to of additional information about substance abuse the member or a less restrictive  Inability to provide for setting such as respite is basic needs, safety and available but deemed not welfare appropriate for the member).  Acute deterioration in mental health functioning causing exacerbation of other medical conditions  The need for regulation of psychotropic medication that cannot be safely done without 24-medical supervision

Revised: November 15, 2018 Effective January 1, 2019 Page 12 of 126

Community Based Intensive Treatment (CBIT) / Intercept Youth SERVICE DESCRIPTION CRITERIA FOR AUTHORIZATION CONCURRENT REVIEW TRANSITION/ DISCHARGE CRITERIA CRITERIA

Community-Based Both must be met: Must meet all of the At least ONE of the following Intensive Treatment (CBIT)  Covered diagnosis on the following: must be met:  Documented treatment is a comprehensive, prioritized list  Capable of additional goals and objectives have individualized service  Current serious to severe symptom or functional been substantially met, functional impairment in improvement at this level package that includes a  multiple areas of care No longer meets criteria mixture of professional, for this level of care or  Evidence of active paraprofessional and meets criteria for a higher And two of the following: discharge planning with level of care, natural supports and  Serious risk of harm to self or the youth/family  Not making progress resources which are others due to symptoms of  Needs cannot be met at toward treatment and intended to maintain or mental illness lower level of care there is no reasonable reintegrate children and  Serious impairment of parent/Youth relationship to expectation of progress at adolescents in their home meet the developmental and this level of care. and community and safety needs  It is reasonably predictable reduce out of home  Significant risk of disruption that continuing placements that are the from current living situation stabilization can occur result of mental health due to symptoms related to a with discharge from issues. Services will be mental health diagnosis. treatment and transition to PCP with medication available in the home,  Transition from a higher level of service intensity (step- management and/or school and community. down) to maintain treatment appropriate community Services and crisis gains supports. intervention will be available 24 hours per day.

Revised: November 15, 2018 Effective January 1, 2019 Page 13 of 126 A face-to-face response  Multiple system involvement will be provided when requiring substantial requested and clinically coordination indicated. Services are  Extended or repeated crisis episode(s) requiring increased time-limited with the goal services of transition to a lower  Significant cultural and level of care. Referrals for language barriers impacting clients in acute care, sub- ability to fully integrate acute or residential symptom management skills settings will be prioritized and there is not more clinically and services will be appropriate service

initiated prior to discharge. Must meet 3 of the following: CBIT differs from Crisis Stabilization in several  Client needs an intake within ways including no 72 hours maximum authorization  Hospital and/or subacute length and that CBIT is not admission within the last used as a diversion from month.  Client needs rapid access to an inpatient hospital medication management or admission. requires medication management on a frequent Authorization Length: 1 basis. month  In order to see improvement, access to in person crisis response or skills training is needed.  Level of aggression requires potentially two on-call staff to respond.

Revised: November 15, 2018 Effective January 1, 2019 Page 14 of 126 Enhanced Community Based Intensive Treatment (ECBIT) Youth SERVICE DESCRIPTION CRITERIA FOR AUTHORIZATION CONCURRENT REVIEW TRANSITION/ DISCHARGE CRITERIA CRITERIA

Enhanced Community-Based Must meet all of the Must meet all of the At least ONE of the following Intensive Treatment (ECBIT) is following: following: must be met:  Documented treatment a comprehensive,  Covered diagnosis on the  Capable of additional goals and objectives have individualized service package prioritized list symptom or functional been substantially met,  Current serious to severe improvement at this level that includes a mixture of  functional impairment in of care No longer meets criteria professional, paraprofessional for this level of care or multiple areas  Evidence of active and natural supports and meets criteria for a higher  Severe crisis and safety discharge planning with level of care, resources which are intended needs require frequent in- the youth/family  Not making progress to maintain or reintegrate person after hours and  Needs cannot be met at toward treatment and children and adolescents in weekend support services. lower level of care there is no reasonable their home and community  Inability to be placed or  Youth continues to be expectation of progress at maintained in a family or unhoused, in a DHS and reduce out of home this level of care. foster care setting due to supervised setting outside placements that are the result  It is reasonably predictable severe emotional or of a family or foster care of mental health issues. that continuing behavioral needs. placement (does not stabilization can occur Services will be available in the  Youth is currently include youth in BRS with discharge from home, school and community. unhoused and living in a setting) treatment and transition Services and crisis intervention DHS supervised setting  Continued need of to PCP with medication will be available 24 hours per (does not include youth in frequent in-person crisis management and/or a BRS setting). and safety support day. A face-to-face response appropriate community services. will be provided when And two of the following: supports. requested and clinically  Serious risk of harm to self indicated. Services are time- or others due to symptoms limited with the goal of of mental illness

Revised: November 15, 2018 Effective January 1, 2019 Page 15 of 126 transition to a lower level of  Serious impairment of care. Referrals for clients in parent/Youth relationship acute care, sub-acute or to meet the residential settings will be developmental and safety needs prioritized and services will be  Current disruption from initiated prior to discharge. living situation due to CBIT differs from Crisis symptoms related to a Stabilization in several ways mental health diagnosis. including no maximum  Transition from a higher authorization length and that level of service intensity CBIT is not used as a diversion (step-down) to maintain treatment gains from an inpatient hospital  Multiple system admission. involvement requiring substantial coordination Authorization Length: 1 month  Extended or repeated crisis episode(s) requiring increased services  Significant cultural and language barriers impacting ability to fully integrate symptom management skills and there is not more clinically appropriate service

Must meet 3 of the following:

 Client needs an intake within 72 hours

Revised: November 15, 2018 Effective January 1, 2019 Page 16 of 126  Hospital and/or subacute admission within the last month.  Client needs rapid access to medication management or requires medication management on a frequent basis.  In order to see improvement, access to in person crisis response or skills training is needed.  Level of aggression requires potentially two on-call staff to respond.

Revised: November 15, 2018 Effective January 1, 2019 Page 17 of 126 Crisis Stabilization Services Youth SERVICE DESCRIPTION CRITERIA FOR AUTHORIZATION CONCURRENT REVIEW TRANSITION/ DISCHARGE CRITERIA CRITERIA

Crisis stabilization services are Must meet all of the following Must meet both of the At least one of the following a rapid response, community criteria: following: must be met: based alternative to inpatient  Youth is an OHP member hospitalization or subacute enrolled with Health Share  Capable of additional  Documented treatment admission for Youth age 4 of Oregon at the time symptom or functional goals and objectives have through their 18th birthday. services are delivered  improvement at this level been substantially met, The intent of these services is  Youth has an OHP covered of care  No longer meets criteria  Evidence of active for this level of care or to allow a Youth to remain in “above-the-line”, DSM 5, discharge planning with meets criteria for a higher the community and to provide non- substance use, diagnosis which is the the youth/ family level of care, stabilization and service focus of the needed  Not making progress planning in a natural setting mental health treatment. toward treatment and where Youth and youth Treatment is not directed there is no reasonable remain connected with family primarily to resolve expectation of progress at and other community placement issues related this level of care supports. The crisis to abuse, neglect or caregiver incapacity OR stabilization team will work behavior, conduct or flexible hours to remain substance use problems. available 24 hours a day, Treatment is likely to including evenings and alleviate symptoms and/or weekends, to meet a family’s improve functioning needs and actively work  Youth cannot be toward transitioning them to a adequately served by other community resources (i.e. less intensive treatment

Revised: November 15, 2018 Effective January 1, 2019 Page 18 of 126 option. These supports are primary care clinics, intended to be short term (30- substance abuse treatment 90 days in length), and will programs, other community resources), include assessment, individual  Youth must have been and family therapy, psychiatric determined to have met care, case management, care medical necessity criteria coordination, skills training for inpatient psychiatric and respite. Psychiatric care hospitalization or will be provided monthly, at psychiatric subacute minimum, and the psychiatrist treatment, or the Youth is discharging from an will be available for at least inpatient hospitalization weekly consultation with the without an established clinical team as needed. mental health provider who can support their Services will be flexible and needs. tailored in frequency,  Substance use/Intoxication intensity, type and duration to or developmental disability must be ruled out as the meet the individual Youth and primary cause of the signs family’s needs. Services will be and symptoms that lead to provided creatively, with the request for treatment attention to what is needed to  The client must be safely maintain the Youth in medically stable and the community setting, and medical causes have been may include flexible services ruled out as the source of the mental or behavioral such as overnight staff in a symptom. family home, skills training  Less restrictive levels of and support at the school, care must have been daily parent coaching, etc. explored, including increasing the intensity of

Revised: November 15, 2018 Effective January 1, 2019 Page 19 of 126 Treatment will be authorized treatment, and 30 days at a time, with a demonstrated to be less maximum of a 90 day service likely to be effective, more intrusive, unavailable or time. Within 30 days of initial too dangerous. treatment, the crisis stabilization team will At least one of the following determine whether continued is present: treatment at a level of care  A clear and reasonable preauthorized by the BHPP’s inference of danger to self (Level D, PRTS, PDTS) is or others necessary in order to sustain a  Dangerous assaultive or high level of community based other uncontrolled support for the Youth and behavior, including family. extensive damage to property, not due to

substance abuse The crisis stabilization team  Inability to provide for will actively work on basic needs, safety and transitioning the Youth to an welfare outpatient provider if it is  Acute deterioration in determined that the Youth mental health functioning does not meet criteria for causing exacerbation of other medical conditions treatment at a level of care

preauthorized by the BHPP’s.

A 30 day authorization will be provided to allow the crisis stabilization team to transition to the next mental health provider.

Revised: November 15, 2018 Effective January 1, 2019 Page 20 of 126 Dialectical Behavior Therapy SERVICE DESCRIPTION CRITERIA FOR AUTHORIZATION CONCURRENT REVIEW TRANSITION/ DISCHARGE CRITERIA CRITERIA Dialectical Behavioral The member must be referred by a The member must meet ALL The member must meet ONE of Therapy (DBT) is a service mental health professional, of the following: the following: requiring an exceptional preferably a current QMHP from a  Member continues to  Continued stay criteria is no needs pre-authorization. DBT contracted agency. meet criteria for OHP longer met is a specialized evidence- covered mental health  Continued progress toward based treatment specifically AND ALL OF THE FOLLOWING: diagnosis and treatment goals can be for members whose needs  Member’s primary diagnosis is an demonstrates ongoing accomplished through less exceed the offerings of other OHP covered mental health capacity and ability to intensive services and available services through diagnosis; engage in and benefit member’s mental health Health Share. Additionally, o Primary medical condition from DBT symptoms can be managed the member’s mental health and/or substance use  Member is actively by routine outpatient condition and symptoms diagnoses have been ruled engaged in DBT program services. should be considered likely to out as primary cause of and treatment  Member shows no use of benefit from more intensive symptoms; components according to crisis/acute care services that will increase o DBT has been shown to be treatment provider services(emergency safety or reduce the need or an efficacious treatment expectations department visits, inpatient, use of more acute and crisis modality for member’s  Member demonstrates subacute, respite) services. presenting problem and progress as measured by  Per clinician report and diagnoses; member’s baseline level treatment plan tracking DBT is a specialized service  Demonstration of recent (within of functioning prior to process, member is applying that is an empirically the last six months) receipt of DBT services. skills learned in DBT to life supported, comprehensive overutilization of acute and crisis This may include the situations the majority of treatment that is effective for services including but not limited following: the time (member is not treating complex mental to hospitalization, subacute, o Decrease in self- expected to be applying health problems (The respite, and provider panel destructive skills 100% of time)

Revised: November 15, 2018 Effective January 1, 2019 Page 21 of 126 Linehan Institute, 2015). DBT resources due to inability of behaviors (suicidal  Despite efforts to address can be applied with a variety outpatient network provider to ideation, self-harm, member’s mental health of mental health problems meet the clinical needs of a suicide attempts) diagnoses and symptoms, and is especially effective for member. o Decrease in acute member is not presently clients who have difficulty  Recurrent suicidal behaviors, psychiatric likely to significantly benefit managing and regulating gestures or threats, or self- symptoms with from further DBT services their emotions, suicidality, mutilating behaviors that are increased due to lack of participation and are high utilizers of crisis unresponsive to multiple functioning in or engagement in services. treatment attempts and do not activities of daily treatment, chronic represent member’s baseline living substance use, or other Initial authorization: 6 level of functioning. o Reduction in number treatment interfering months  There is an adequate and well of crisis and acute behavior(s). Continued Stay documented trial of outpatient care services authorization: 6 months treatment that has been (emergency ineffective at addressing department visits, member’s symptoms and inpatient, subacute, behaviors (i.e., history of respite) appropriate outpatient o Objective signs of treatment not being able to increased decrease use of crisis services, engagement suicidal ideation, and/or suicide o Demonstrated attempts). increase in  Member needs to be in application of skills treatment with current learned in DBT to life outpatient provider, preferably situations per Health Share contracted treatment plan provider, unless there is an progress, clinician extenuating circumstance that report, and use of prevents this. the safety plan

Revised: November 15, 2018 Effective January 1, 2019 Page 22 of 126  Documented history of multiple  Member continues to unsuccessful outpatient make progress toward treatment episodes. goals but has not fully  Member demonstrates capacity demonstrated an ability to engage in the DBT treatment to self-manage and use modality and no interfering learned skills effectively. factors are present that may limit  Active discharge planning member’s ability to benefit from begins at admission and DBT treatment (i.e., limited continues throughout cognitive capacity, psychosis, treatment. Provider and chronic methamphetamine use, member are actively medical condition). This will be working toward discharge determined by UR specialist’s and being able to manage clinical judgment. mental health symptoms  Member is not dependent on by routine outpatient and is not actively abusing provider. substances that are likely to  Provider should actively interfere with benefitting from be working on DBT services. transitioning member to  There must be a reasonable less intensive outpatient expectation that DBT will provider when member stabilize and/or improve the seems to be nearing member’s symptoms and readiness for transition. behaviors.

Revised: November 15, 2018 Effective January 1, 2019 Page 23 of 126 Eating Disorder Treatment Eating Disorder Treatment: Partial Hospitalization (IOP) Services SERVICE DESCRIPTION CRITERIA FOR AUTHORIZATION CONCURRENT REVIEW CRITERIA TRANSITION/ DISCHARGE CRITERIA Structured, short term Medical: Continued stay is based on  Continued stay criteria no treatment setting.  Medically stable progress in treatment or longer met Generally services are treatment plan is reviewed  Continued progress provided for a minimum of Suicidality: and amended to eliminate toward treatment goals 6 hours per day, 5 days per  None present barriers to achieving discharge can be accomplished at a week.  If present, consider if program goals. less intensive level of care is equipped to handle or  After an adequate trial Partial hospitalization may another level of care should be Progress as indicated by that includes be used as a “step down” considered general trending upward of: reformulation of from inpatient services to  BMI if client if treatment interventions, assist the individual with Weight as % of healthy body anorectic member does not show transition to outpatient weight:  % of meals completed measurable progress in services.  Generally>80% without supervision if treatment anorectic.  Behavioral, psychological Partial hospitalization is Presence of Distorted Body Image or medical problems also used when outpatient as defined by: Progress as indicated by necessitate transfer to a treatment has been or is  A brain disorder that causes general trending downward more intensive level of expected to be preoccupation with an of: care unsuccessful or the imagined defect in  Incidents of restricting  Discharging the member individual’s symptoms appearance, or if a slight without supervision to a less intensive level of cannot be managed in an physical anomaly is present,  Incidents of purging care does not pose a outpatient setting. the person's concern is without supervision threat to the individual, markedly excessive. The  Incidents of over- others, or property The individual must have preoccupation causes clinically exercising when the ability to control eating significant distress or unsupervised disorder behaviors and be impairments in daily safely treated at this level functioning. Symptoms of care.

Revised: November 15, 2018 Effective January 1, 2019 Page 24 of 126 overlap with primary eating The individual is motivated disorders and therefore and is actively engaged in the cannot be diagnosed as a treatment process. separate condition during the active eating disorder. Active discharge planning to include natural supports (if Motivation: available) in terms of  Partial motivation developing plan to maintain  Cooperative treatment gains.  Preoccupied with intrusive thoughts >3 hours/day

Co-occurring:  Presence of comorbid condition may influence choice of level of care including other medical conditions, substance use, etc.  Consider impact of mental health condition on eating disorder

Structure needed for eating/weight gain:  Needs some structure to gain weight

Ability to control compulsive exercising:  Some degree of external structure beyond self-control

Purging Behaviors:

Revised: November 15, 2018 Effective January 1, 2019 Page 25 of 126  Can greatly reduce incidents of purging in an unstructured setting  No significant medical complications such as electrocardiographic or other abnormalities resulting in the need for potential hospitalization

Environmental Stress Others able to provide at least limited support and structure

Eating Disorder Treatment: Residential Treatment SERVICE DESCRIPTION CRITERIA FOR AUTHORIZATION CONCURRENT REVIEW CRITERIA TRANSITION/ DISCHARGE CRITERIA Residential treatment Medical: Continued stay is based on  Continued stay criteria no provides intensive, 24 hour  Medically stable to the extent progress in treatment or longer met services in an that intravenous fluids, treatment plan is reviewed  Continued progress appropriately licensed nasogastric tube feedings, or and amended to eliminate toward treatment goals mental health facility. multiple daily laboratory tests barriers to achieving discharge can be accomplished at a Services are provided by a are not needed goals. less intensive level of care multidisciplinary team  After an adequate trial under the supervision of a Suicidality: Progress as indicated by that includes licensed psychiatrist and  None present. general trending upward of: reformulation of are focused on reducing  If present, consider if program  BMI if client if treatment interventions, immediate risk due to is equipped to handle or anorectic member does not show dangerousness to self, another level of care should be  % of meals completed measurable progress in grave disability, or considered without staff direction. treatment complicating medical  Behavioral, psychological conditions. or medical problems

Revised: November 15, 2018 Effective January 1, 2019 Page 26 of 126 Weight as % of healthy body Progress as indicated by necessitate transfer to a weight: general trending downward more intensive level of  Generally <85% of: care  Incidents of restricting  Discharging the member Presence of Distorted Body Image without staff direction to a less intensive level of as defined by:  Incidents of purging care does not pose a  A brain disorder that causes without staff direction threat to the individual, preoccupation with an  Incidents of over- others, or property imagined defect in exercising without staff appearance, or if a slight direction. physical anomaly is present, the person's concern is The individual is motivated markedly excessive. The and is actively engaged in the preoccupation causes clinically treatment process. significant distress or impairments in daily Active discharge planning to functioning. Symptoms include natural supports (if overlap with primary eating available) in terms of disorders and therefore developing plan to maintain cannot be diagnosed as a treatment gains. separate condition during the active eating disorder.

Motivation:  Poor to Fair motivation  Cooperative with highly structured treatment  Preoccupied with intrusive thoughts 4-6 hours/day

Co-occurring:  Presence of comorbid condition may influence

Revised: November 15, 2018 Effective January 1, 2019 Page 27 of 126 choice of level of care including other medical conditions, substance use, etc.  Consider impact of mental health condition on eating disorder

Structure needed for eating/weight gain:  Needs supervision at all meals or will restrict eating

Ability to control compulsive exercising:  Some degree of external structure beyond self-control

Purging Behaviors:  Can ask for and use support from others or use cognitive and behavioral skills to inhibit purging

Environmental Stress  Severe family conflict or problems or absence of family so member is unable to receive structured treatment in home OR Member lives alone without adequate support system

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Eating Disorder Treatment: Inpatient Hospitalization Services SERVICE DESCRIPTION CRITERIA FOR AUTHORIZATION CONCURRENT REVIEW CRITERIA TRANSITION/ DISCHARGE CRITERIA Structured eating disorder Medical: Adults Continued stay will be based  Continued stay criteria no treatment program  Heart rate <40 bpm on review of the longer met occurring in a medical  Blood Pressure <90/60 mmHg interdisciplinary medical  Continued progress hospital with focus on  Glucose <60mg/dl record which provides toward treatment goals eating disorder and not  Potassium <3 mEq/L evidence of the individual’s: can be accomplished at a just for medical  Electrolyte imbalance less intensive level of care stabilization.  Temperature <97.0F  failure to meet targeted  After an adequate trial  Dehydration weight after adequate that includes Services are provided by a  Hepatic, renal, or caloric intake; and reformulation of multidisciplinary cardiovascular organ treatment interventions, treatment team under the compromise requiring acute  inability to control binging member does not show supervision of a licensed treatment OR and purging that require measurable progress in psychiatrist and are  Poorly controlled diabetes supervision of meal treatment focused reducing consumption and locked  Behavioral, psychological immediate risk due to Medical: Youth bathroom; and or medical problems dangerousness to self,  Heart rate near 40 bpm necessitate transfer to a grave disability, or  Orthostatic Blood Pressure  lack of insight into more intensive level of complicating medical changes (> 20 bpm increase in symptoms, illness, and care conditions. heart rate or >10 mmHG to 20 cannot ambulate safely; or  Discharging the member mmHg drop) to a less intensive level of  Blood pressure <80/50 mmHG  start on a trial of a new care does not pose a  Hypokalemia, medication and requires threat to the individual, hypophosphatemia, or monitoring for adverse others, or property hypomagnesemia side effects or reactions.

Suicidality:  Specific plan with high lethality or intent; admission may also

Revised: November 15, 2018 Effective January 1, 2019 Page 29 of 126 be indicated in members with suicidal ideas or after attempt or aborted attempt, depending on the presence or absence of other factors modulating suicide risk

Weight as % of healthy body weight:  Generally <85% OR  Acute weight decline with food refusal even if not <85% of healthy body weight

Presence of Distorted Body Image as defined by:  A brain disorder that causes preoccupation with an imagined defect in appearance, or if a slight physical anomaly is present, the person's concern is markedly excessive. The preoccupation causes clinically significant distress or impairments in daily functioning. Symptoms overlap with primary eating disorders and therefore cannot be diagnosed as a separate condition during the active eating disorder.

Revised: November 15, 2018 Effective January 1, 2019 Page 30 of 126 Motivation:  Very Poor to poor motivation  Uncooperative or cooperative only in highly structured treatment  Preoccupied with intrusive, repetitive thoughts Co-occurring:  Presence of comorbid condition may influence choice of level of care including other medical conditions, substance use, etc.  Consider impact of mental health condition on eating disorder

Structure needed for eating/weight gain:  Needs supervision during and after all meals OR  nasogastric/special feeding modality

Ability to control compulsive exercising:  Some degree of external structure beyond self-control

Purging Behaviors:  Needs supervision during and after all meals and in bathrooms

Revised: November 15, 2018 Effective January 1, 2019 Page 31 of 126  Unable to control multiple daily episodes of purging that are severe, persistent, and disabling despite appropriate trials of outpatient care, even if routine laboratory test results reveal no obvious metabolic abnormalities

Environmental Stress  Severe family conflict or problems or absence of family so member is unable to receive structured treatment in home OR  Member lives alone without adequate support system

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Electroconvulsive Therapy SERVICE DESCRIPTION CRITERIA FOR AUTHORIZATION CONCURRENT REVIEW TRANSITION/ DISCHARGE CRITERIA CRITERIA

Electroconvulsive Therapy The decision to administer ECT ECT is generally authorized for Discharge may occur when: (ECT) is an exceptional needs must be based on an 6 to 12 sessions.  Continued progress treatment intervention evaluation of the risks and toward treatment goals considered only after various benefits involving a Additional sessions may be can be accomplished at a trials of different therapies combination of factors that authorized in the following less intensive level of care. and medications, of various include psychiatric diagnosis, circumstances: OR classes, have been exhausted. type and severity of symptoms, prior treatment  Persistence of symptoms  After an adequate ECT must be conducted in a history and response, and with improvement but treatment trial has been fully equipped medical facility identification of possible where maximum benefit completed that includes a with the capability to manage alternative treatment options. has not been achieved reformulation of any complications. An OR treatment interventions, anesthesiologist assists in the A request for an ECT  New symptoms or procedure that can be assessment must be made in problems that meet OR provided either on an writing by the prescriber clinical criteria for ECT inpatient or outpatient basis. (either a licensed psychiatrist have emerged.  Individual does not show or psych nurse practitioner) to measurable progress in ECT is generally used as a the assigned Behavioral Health treatment. secondary treatment when Plan Partner (BHPP). Client the individual has not must voluntarily agree to ECT OR responded to medication assessment. and/or psychotherapy.  Authorized sessions have BHPP Medical Directors will been completed. ECT can be used if previous determine whether or not ECT treatment brought about criteria are met for an favorable results for the assessment to be covered by patient. an ECT provider.

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ECT can also be used if the To be considered for an ECT patient is pregnant and has assessment, the individual severe mania or depression must meet the following and the risks of providing no criteria: treatment outweigh the risks of providing ECT.  A Diagnosis of either Major Depression, Bipolar ECT is not to be used in the Affective Disorder or presence of cognitive or Catatonia associated with neurological deficits another medical or mental disorder. AND  History of severe suicidal ideation and/or vegetative state,

AND/OR  High level of acuity at time of request must be demonstrated not only chronicity of symptoms.

Revised: November 15, 2018 Effective January 1, 2019 Page 34 of 126 Outpatient Mental Health Services – Level A-D Youth and Family Assessment Plus Two The assessment plus two authorization covers up to three sessions with no time limit. The purpose of this assessment phase is threefold: (1) gather adequate clinical information to recommend the appropriate Level of Care (LOC); (2) assess the client’s ability and willingness to engage in treatment; and (3) determine the client’s functional capacity.

Please note that initial engagement and assessment/screening services (e.g. 90899, T1023, 90791, 90792, H0002, H0031) do not require a covered diagnosis on the 32Tprioritized list32T. However, if other clinical services such as individual or family therapy are employed as part of the Assessment Plus Two process, they do require a covered diagnosis on the prioritized list, as well as an assessment and service plan in compliance with applicable OARs and the fee schedule. Level A-D Determination of Level of Care There may be specific situations when the clinician determines that a particular LOC is appropriate, based on their assessment of the client’s clinical presentation and needs; however, the client is either unable or unwilling to engage in treatment at that level. That inability to engage can be secondary to either a lack of interest in treatment and/or functional limitations in their ability to engage. In those situations, the clinician may request authorization at a lower LOC, to reflect the client’s interest/readiness for change and/or functional ability to participate.

If a clinician decides to request authorization at a lower LOC than is clinically indicated (per the paragraph above), the LOC Registration form requires that the clinician explain how he/she will work with the client towards the goal of receiving all clinically indicated services.

Revised: November 15, 2018 Effective January 1, 2019 Page 35 of 126 Mental Health Outpatient: Level A Youth and Family SERVICE DESCRIPTION CRITERIA FOR AUTHORIZATION CONCURRENT REVIEW CRITERIA TRANSITION/ DISCHARGE CRITERIA

Generally office based, these  Covered diagnosis on the Continues to meet admission At least ONE of the following outpatient mental health prioritized list AND criteria AND is capable of must be met: services are designed to  The need for maintenance of additional symptom or quickly promote, or restore, a medication regimen (at functional improvement at  Documented treatment goals least quarterly)that cannot previous level of high this level of care. and objectives have been be safely transitioned to a substantially met, function/stability, or maintain PCP, OR  No longer meets criteria for social/emotional functioning  A mild or episodic parent- this level of care or meets and are intended to be Youth or family system criteria for a higher level of focused and time limited with interactional problem that is care, triggered by a recent services discontinued as an  Not making progress toward transition or outside event individual is able to function treatment and there is no and is potentially resolvable more effectively. reasonable expectation of in a short period of time OR progress at this level of care,  Transitioning from a higher  It is reasonably predictable Outpatient services include level of service (step down) in that continuing stabilization evaluation and assessment; order to maintain treatment can occur with discharge gains and has been stable at individual and family therapy; from treatment and his level of functioning for 3-4 group therapy; medication transition to PCP for with visits AND management; and case medication management  Low acuity of presenting management. and/or appropriate symptoms and minimal community supports. functional impairment AND Examples Include:  Home, school, community

 An individual has already impact is minimal taken effective action and is

Revised: November 15, 2018 Effective January 1, 2019 Page 36 of 126 in the maintenance phase of treatment to maintain baseline  Client who is pre- contemplative regarding

engagement in a higher level of care  Primarily psychiatric services for on-going medication management  Treatment will be limited and target a specific behavior, interaction, or symptom  Natural supports are available consistently. Important life activities prohibit frequent participation in services.  Client who is receiving services from other systems such as DD, APD, DHS, etc.

Authorization Length: One year

Revised: November 15, 2018 Effective January 1, 2019 Page 37 of 126 Mental Health Outpatient: Level B Youth and Family SERVICE DESCRIPTION CRITERIA FOR CONCURRENT REVIEW CRITERIA TRANSITION/ DISCHARGE AUTHORIZATION CRITERIA

Generally office based, these  Covered diagnosis on the Continues to meet admission At least ONE of the following outpatient mental health services prioritized list AND criteria AND at least one of must be met: are designed to promote, restore,  Mild to Moderate the following: or maintain social/emotional functional impairment in  Capable of additional  Documented treatment goals at least one area (for functioning and are intended to symptom or functional and objectives have been example, sleep, eating,  improvement at this level substantially met, be focused and time limited with self-care, relationships, of care  No longer meets criteria for services discontinued as an school behavior or  Significant cultural and this level of care or meets individual is able to function achievement) OR language barriers criteria for a higher level of more effectively.  Mild to Moderate  impacting ability to fully care, impairment of integrate symptom  Not making progress toward parent/Youth relationship Outpatient services may include  management skills and treatment and there is no to meet the some combination of evaluation there is no more clinically reasonable expectation of developmental and safety appropriate service progress at this level of care, and assessment; individual and needs OR  It is reasonably predictable family therapy; group therapy;  Transition from a higher that continuing stabilization medication management; and as level of service intensity can occur with discharge (step-down) to maintain needed case management, skills from treatment and treatment gains training, and peer/family support. transition to PCP for with medication management Examples include: and/or appropriate  An individual who is taking community supports. effective action in treatment or who is prepared and determined to take effective action in treatment.

Revised: November 15, 2018 Effective January 1, 2019 Page 38 of 126  Client who is pre-contemplative regarding engagement in a higher level of care  Low frequency sessions, but client/family requires consistency and regular practice over time in order to develop new skills. ,habits and routines to compensate for lagging skills  Parent-child interactional problem may be causing some on-going impairment, therefore parent training may be a primary focus of treatment  Client may have more barrier to natural/informal supports and requires case management  Family utilizes services well and benefits from treatment, but struggles to internalize or generalize skill development  Home based services may be appropriate when there are cultural or developmental considerations

Authorization Length: Six months

Revised: November 15, 2018 Effective January 1, 2019 Page 39 of 126 Mental Health Outpatient: Level C Youth and Family SERVICE DESCRIPTION CRITERIA FOR AUTHORIZATION CONCURRENT REVIEW TRANSITION/ DISCHARGE CRITERIA CRITERIA

These services can be Criteria for Early Childhood and Continues to meet At least ONE of the following provided in any of the School-Age and Adolescents: admission criteria AND at must be met: following: clinic, home, school  Covered diagnosis on the least one of the following:  Documented treatment and community. These prioritized list  Capable of additional goals and objectives have services are designed to symptom or functional been substantially met, prevent the need for a higher At least one of the following: improvement at this level  No longer meets criteria for this level of care or level of care, or to sustain the  Significant risk of harm to self of care or others  Significant cultural and meets criteria for a higher gains made in a higher level of  Moderate to severe language barriers level of care, care, and which cannot be impairment of parent/Youth impacting ability to fully  Not making progress accomplished in either routine relationship to meet the integrate symptom toward treatment and outpatient care or other developmental and safety  Management skills and there is no reasonable community support services. needs there is no more clinically expectation of progress at  Moderate to severe appropriate service this level of care,  It is reasonably predictable Outpatient services may functional or developmental impairment in at least one that continuing include some combination of area, stabilization can occur evaluation and assessment; with discharge from individual and family therapy; AND For School-Age and treatment and transition to PCP for with medication medication management, case Adolescents at least one of the management and/or management, skills training, following: peer/family support, respite appropriate community  Risk of out of home supports. and some phone crisis support placement or has had multiple transition in Examples include: placement in the last 6

Revised: November 15, 2018 Effective January 1, 2019 Page 40 of 126  Client who is pre- months due to symptoms of contemplative regarding mental illness engagement in a higher level  Risk of school or daycare of care placement loss due to mental  Client needs higher illness or development needs. frequency of sessions and a  Multiple system involvement combination of multiple requiring coordination and service types case management  In vivo coaching and mild to  Moderate to severe moderate phone crisis behavioral issues that cause support required to interrupt chronic family disruption dysfunctional patters of  Extended crisis episode interaction and integrate requiring increased services; new skills  Recent acute or subacute  Unstable placement due to admission (within the last 6 caregiver stress months)  Complex symptoms for  Significant current substance which targeted caregiver abuse for which integrated /parent education is required treatment is necessary to improve child function  Transition from a higher level of service intensity (step-

down) to maintain treatment Authorization Length: Six gains months  Youth and/or family’s level of English language skill and/or acculturation is not sufficient to achieve symptom or functional improvement without case management

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Mental Health Outpatient: Level D Early Childhood: Ages 0-5 SERVICE DESCRIPTION CRITERIA FOR AUTHORIZATION CONCURRENT REVIEW CRITERIA TRANSITION/ DISCHARGE CRITERIA

Early Childhood Home based All must be met: Must meet all of the At least ONE of the following stabilization services are - Covered diagnosis on the following: must be met: provided, at an intensive level, prioritized list - Capable of additional - Documented treatment goals in the home, school and - Current serious to severe symptom or functional and objectives have been community with the goal of functional impairment in stabilizing behaviors and multiple areas improvement at this level of substantially met, symptoms of the child that led - Treatment intensity at a care -No longer meets criteria for to referral. May include some lower level of care insufficient - Parent or caregiver is actively this level of care or meets combination of evaluation and to maintain functioning involved with treatment criteria for a higher level of assessment; individual and -Evidence of active discharge care, family therapy (including And four of the following: planning with the -Not making progress toward evidenced based early -Serious risk of harm to self or youth/family treatment and there is no childhood models); medication others due to symptoms of management; case mental illness (e.g. impulsivity - Needs cannot be met at lower reasonable expectation of management; skills training; resulting in elopement, level of care progress at this level of care, peer/family support; respite at aggression, sexualized -It is reasonably predictable an increased frequency; behaviors, expressed intent to that continuing stabilization school/day care support and harm self or others, extreme can occur with discharge from consultation; group parenting irritability resulting in unsafe treatment and transition to education/training. Treatment responses from others, etc.…) Lower level of care with is not directed primarily to resolve placement OR - Serious impairment of medication management behavior. caregiver capacity to meet the and/or appropriate developmental and safety community supports. needs of their child (e.g. parent in substance abuse

Revised: November 15, 2018 Effective January 1, 2019 Page 42 of 126 Services and interventions treatment, domestic violence, should be focused on both mental illness, etc.) young child and caregiver. - Significant risk of disruption Crisis intervention is available from current living situation 24/7 both by phone and in due to child’s symptoms person. May be appropriate as related to a mental health an alternative to Psychiatric diagnosis. Day Treatment, Psychiatric Residential Treatment, or - Significant cultural and Inpatient Treatment. language barriers impacting ability to fully integrate Typically children referred to symptom management skills this level of care are and there is not more clinically demonstrating attachment appropriate service and/or trauma related symptoms resulting in possible -Multiple recent placement loss of early childhood changes for child resulting in placement. increase in emotional / Authorization Length: Initial behavioral dysregulation 90 days, one month thereafter -Current significant risk of For the initial 90 day losing day care or early authorization request, the childhood education provider will submit the placement due to behaviors following: related to mental health Mental Health Assessment symptoms or trauma (e.g. updated within the last 60 days sexualized behavior, increased OR progress notes for the last arousal, persistent negative 30 days AND emotional state, biting, Updated Treatment Plan extreme tantrums, aggression towards others, etc.)

Revised: November 15, 2018 Effective January 1, 2019 Page 43 of 126 For all subsequent 30 day authorization requests, the provider will either have a verbal conversation with ENCC to justify continued stay OR submit the last 30 days of progress notes. In the event of a potential denial via the verbal authorization, backup clinical would be requested prior to the NOA.

The Health Plan will be responsible for the completion of the Level of Care Treatment Registration Form

Revised: November 15, 2018 Effective January 1, 2019 Page 44 of 126 Level D (Home Based Stabilization) Youth and Family - Ages 6 -17 SERVICE DESCRIPTION CRITERIA FOR AUTHORIZATION CONCURRENT REVIEW CRITERIA TRANSITION/ DISCHARGE CRITERIA

Home based stabilization Both must be met: Continues to meet admission At least ONE of the following services are provided, at an  Covered diagnosis on the criteria AND at least one of the must be met: intensive level, in the home, prioritized list following:  Documented treatment school and community with  Current serious to severe  Capable of additional goals and objectives have the goal of stabilizing behaviors functional impairment in symptom or functional been substantially met, and symptoms that led to multiple areas improvement at this level of  No longer meets criteria referral. May include some care for this level of care or combination of evaluation and And one of the following:  Significant cultural and meets criteria for a higher assessment; individual and  Treatment intensity at a language barriers impacting level of care, family therapy; medications lower level of care ability to fully integrate  Not making progress management; case insufficient to maintain symptom management skills toward treatment and management; skills training; functioning and there is not more there is no reasonable peer/family support, and  Hospital or subacute clinically appropriate service expectation of progress at respite at an increased admission in the last 30 this level of care, frequency. Treatment is not days  It is reasonably predictable directed primarily to resolve that continuing placement OR behavior, And two of the following: stabilization can occur conduct or substance abuse  Serious risk of harm to self with discharge from problems or others due to symptoms treatment and transition of mental illness to PCP with medication Crisis intervention is available  Serious impairment of management and/or 24/7 both by phone and in parent/Youth relationship appropriate community person. to meet the developmental supports. and safety needs Examples:  Significant risk of disruption from current living

Revised: November 15, 2018 Effective January 1, 2019 Page 45 of 126  Client who is pre- situation due to symptoms contemplative regarding related to a mental health engagement in a higher diagnosis. level of care  Transition from a higher level of service intensity  Client is discharging from (step-down) to maintain residential stay or has had treatment gains multiple acute/sub-acute  Significant cultural and placements in the last 6 language barriers impacting months. ability to fully integrate symptom management Children and Youth are no skills and there is not more longer required to meet clinically appropriate service criteria for Wraparound Care

Coordination to be considered for this level of care.

Authorization Length: Initial 90 days, one month thereafter

For the initial 90 day authorization request, the provider will submit the following:  Mental Health Assessment updated within the last 60 days OR progress notes for the last 30 days AND  Updated Treatment Plan

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For all subsequent 30 day authorization requests, the provider will either have a verbal conversation with ENCC to justify continued stay OR submit the last 30 days of progress notes. In the event of a potential denial via the verbal authorization, backup clinical would be requested prior to the NOA.

The Health Plan will be responsible for the completion of the Level of Care Treatment Registration Form

Revised: November 15, 2018 Effective January 1, 2019 Page 47 of 126 Outpatient Mental Health Services – Level A-D Adult Assessment Plus Two The assessment plus two authorization covers up to three sessions with no time limit. The purpose of this assessment phase is threefold: (1) gather adequate clinical information to recommend the appropriate Level of Care (LOC); (2) assess the client’s ability and willingness to engage in treatment; and (3) determine the client’s functional capacity.

Please note that initial engagement and assessment/screening services (e.g. 90899, T1023, 90791, 90792, H0002, H0031) do not require a covered diagnosis on the prioritized list. However, if other clinical services such as individual or family therapy are employed as part of the Assessment Plus Two process, they do require a covered diagnosis on the prioritized list, as well as an assessment and service plan in compliance with applicable OARs and the fee schedule. Level A-D Determination of Level of Care There may be specific situations when the clinician determines that a particular LOC is appropriate, based on their assessment of the client’s clinical presentation and needs; however, the client is either unable or unwilling to engage in treatment at that level. That inability to engage can be secondary to either a lack of interest in treatment and/or functional limitations in their ability to engage. In those situations, the clinician may request authorization at a lower LOC, to reflect the client’s interest/readiness for change and/or functional ability to participate.

If a clinician decides to request authorization at a lower LOC than is clinically indicated (per the paragraph above), the LOC Registration form requires that the clinician explain how he/she will work with the client towards the goal of receiving all clinically indicated services.

Revised: November 15, 2018 Effective January 1, 2019 Page 48 of 126 Mental Health Outpatient: Level A: MRDD/IDD or Medication Only Adult SERVICE DESCRIPTION CRITERIA FOR CONCURRENT REVIEW CRITERIA TRANSITION/ DISCHARGE AUTHORIZATION CRITERIA Specialized assessment and  Covered diagnosis on Continues to meet admission At least ONE of the following medication management by a MD the prioritized list criteria AND is capable of must be met: or PMHNP and minimal adjunct additional symptom or AND one of the case management functional improvement at this  Documented treatment following: level of care. goals and objectives have

Examples include: been substantially met  Need for care  Continuing stabilization  Individual with a coordination with DD can occur with discharge developmental disability that services and ongoing from treatment with will not benefit from talk medication medication management therapy. management by PCP and/or appropriate  Client who is pre-  Need for medication community supports contemplative regarding management for a  Individual has achieved engagement in a higher level medication regime symptom or functional of care that is more improvement in resolving  Individuals that have complicated than issues resulting in progressed to the point in care generally provided in admission to this level of where they only require primary care. care complex medication  Meets criteria for a management (e.g. injectable different level of care due medications) to change in symptoms or  For adults only medication, this function at this level of can be clients in a general care outpatient setting or who fit the criteria for Severe and

Persistently Mentally Ill (SPMI) Authorization Length:1 year

Revised: November 15, 2018 Effective January 1, 2019 Page 49 of 126 Mental Health Outpatient: Level A Adult (Note: There is no “Level A SPMI”) SERVICE DESCRIPTION CRITERIA FOR CONCURRENT REVIEW CRITERIA TRANSITION/ DISCHARGE AUTHORIZATION CRITERIA

Services are designed to Both of the following: Continues to meet admission At least ONE of the following promote, restore, or maintain  Covered diagnosis on criteria AND at least one of the must be met: social/emotional functioning the prioritized list following: and are focused and time  Episodic depression,  Documented treatment limited with services anxiety or other mental  Capable of additional goals and objectives have health conditions with discontinued when client’s symptom or functional been substantially met no recent  Continuing stabilization functioning improves. improvement at this level of hospitalizations and care can occur with discharge limited crisis episodes  Significant cultural and from treatment with Outpatient services include within the past year language barriers impacting medication management

evaluation and assessment; ability to fully integrate by PCP and/or individual and family therapy; AND at least one of the symptom management skills appropriate community group therapy; medication following: and there is no more clinically supports management. appropriate service  Individual has achieved symptom or functional  Mild functional improvement in resolving impairment Outpatient services are office issues resulting in  A presentation that is based. admission to this level of elevated from baseline care

Examples include:  Meets criteria for a  Mild depression or anxiety different level of care due that cannot be addressed to change in symptoms or only by primary care function at this level of intervention. care

Revised: November 15, 2018 Effective January 1, 2019 Page 50 of 126  Client who is pre- contemplative regarding engagement in a higher level of care

Authorization Length:1 year

Mental Health Outpatient: Level B Adult SERVICE DESCRIPTION CRITERIA FOR CONCURRENT REVIEW CRITERIA TRANSITION/ DISCHARGE AUTHORIZATION CRITERIA

Services are designed to  Covered diagnosis on the Continues to meet admission At least ONE of the following promote, restore, or maintain prioritized list criteria AND at least one of the must be met: social/emotional functioning following: and are focused and time AND at least one of the  Documented treatment limited with services following: goals and objectives have discontinued when client’s  Capable of additional been substantially met functioning improves. symptom or functional  Continuing stabilization  Moderate risk of harm to improvement at this level of can occur with discharge Services may include self or others care from treatment with evaluation and assessment;  Moderate functional  Significant cultural and medication management individual and family therapy; impairment in at least language barriers impacting by PCP and/or group therapy; medication one area such as such as ability to fully integrate appropriate community management. Case housing, financial, social, symptom management skills supports management is not generally occupational, health, and and there is no more clinically  Individual has achieved required by individual. activities of daily living appropriate service symptom or functional  Individual has a improvement in resolving Outpatient services are more marginalized identity issues resulting in commonly provided in the which creates barriers to

Revised: November 15, 2018 Effective January 1, 2019 Page 51 of 126 office and with more receiving appropriate admission to this level of frequency than Level A. services, and/or care individual’s level of Meets criteria for a Examples include: English language skill different level of care due  Moderate risk of harm to and/or cultural to change in symptoms or self or others requiring navigation barriers is not function at this level of more frequent sessions sufficient to achieve care  Client who is pre- symptom or functional contemplative regarding improvement without engagement in a higher additional supports level of care  Individual is stepping down from higher level of care and demonstrating symptom or functional improvement  Individual’s clinical presentation is affecting at least one functional domain such as work or relationships and therefore would benefit from more frequent services Authorization Length:1 year

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Mental Health Outpatient: Level B SPMI Adult SERVICE DESCRIPTION CRITERIA FOR CONCURRENT REVIEW CRITERIA TRANSITION/ DISCHARGE AUTHORIZATION CRITERIA

Services are designed to ALL of the following: Continues to meet admission At least ONE of the following promote recovery and criteria AND at least one of the must be met: rehabilitation for adults with  Covered diagnosis on the following: SPMI. These services instruct, prioritized list  Documented treatment assist, and support an  No hospitalizations or  Capable of additional symptom goals and objectives have individual to build or improve major crisis episodes or functional improvement at been substantially met within the past year skills that have been impaired this level of care  Continuing stabilization  No risk of harm to self or can occur with discharge by these symptoms.  Significant cultural and others or risk of harm to language barriers impacting from treatment with Comprehensive assessment self or others that is ability to fully integrate medication management and treatment planning focus consistent with baseline symptom management skills by PCP and/or on outcomes and goals with presentation. and there is no more clinically appropriate community specific interventions appropriate service supports described to achieve them. AND at least two of the  Individual has achieved Emphasis is placed on following: symptom or functional improvement in resolving linkages with other services issues resulting in  Symptoms related to the and coordination of care. admission to this level of mental illness result in a care moderate functional Services are primarily office  Meets criteria for a impairment and are fairly different level of care due based and may include well controlled evaluation and assessment; to change in symptoms or

Revised: November 15, 2018 Effective January 1, 2019 Page 53 of 126 consultation; case  Individual able to function at this level of management; individual and navigate system with care family therapy; group therapy; minimal to moderate medication management; support OR has supports (such as family or AFH) in skills training; supported place to meet client’s employment; family education needs and support; relapse  Low to moderate prevention; occasional crisis psychosocial stress support. (housing and benefits are generally stable) Diagnoses generally covered  Individual is generally functioning at baseline under this authorization type:  Individual has extended Schizophrenia; Schizoaffective periods of abstinence Disorder; and Psychosis. when a co-occurring Diagnoses can also include disorder exists and risk Mood and Anxiety Disorders factors are minimal that are severe and persistent  Individual has a in nature and have serious marginalized identity which creates barriers to impact on activities of daily receiving appropriate living. services, and/or individual’s level of Examples include: English language skill  Individuals functioning at and/or cultural baseline would benefit navigation barriers is not from additional life skill sufficient to achieve development and social symptom or functional support in order to improvement without maintain independence additional supports

Revised: November 15, 2018 Effective January 1, 2019 Page 54 of 126  Client who is pre- contemplative regarding engagement in a higher level of care  Individual is stepping down from higher level of care and demonstrating symptom or functional improvement Foster home example or natural supports example--- supported structure living

Authorization Length: One Year

Mental Health Outpatient: Level C Adult SERVICE DESCRIPTION CRITERIA FOR AUTHORIZATION CONCURRENT REVIEW TRANSITION/ DISCHARGE CRITERIA CRITERIA

Services are designed to  Covered diagnosis on the Continues to meet admission At least ONE of the following promote, restore, or prioritized list criteria AND at least one of must be met: maintain social/emotional the following: AND at least two of the following functioning and are  Documented treatment must be met: intended to be focused  Capable of additional goals and objectives have  Risk of harm to self or others or and time limited with symptom or functional been substantially met risk of harm to self or others  Continuing stabilization services discontinued improvement at this level of that is escalated from baseline care can occur with discharge when client’s functioning from treatment with

Revised: November 15, 2018 Effective January 1, 2019 Page 55 of 126 improves. This includes  Moderate functional  Significant cultural and medication management individuals who meet the impairment in at least two language barriers impacting by PCP and/or criteria for Transitional Age areas (such as housing, ability to fully integrate appropriate community financial, social, occupational, supports Youth. symptom management skills health, activities of daily living.) and there is no more  Individual has achieved

 At least one hospitalization clinically appropriate service symptom or functional Services may include more within the last 6 months improvement in resolving community-based services  Multiple system involvement issues resulting in and can include evaluation requiring coordination and case admission to this level of and assessment; individual management care and family therapy; group  Risk of loss of current living  Meets criteria for a situation, in an unsafe living different level of care due therapy; medication situation, or currently homeless to change in symptoms or management; due to symptoms of mental function at this level of consultation; case illness care management; skills  Significant current substance training; crisis support; abuse for which integrated relapse prevention, treatment is necessary hospital diversion;  Significant PTSD or depression symptoms as a result of integrated substance torture, ongoing systemic abuse treatment oppression, trauma or multiple losses Examples Include:  Extended or repeated crisis  Mental health issues episode(s) requiring increased are compounded by services risk of loss of housing  Individual has a marginalized due to extended identity which creates barriers periods of crisis to receiving appropriate  Individual may benefit services, and/or individual’s from care coordination level of English language skill and case management and/or cultural navigation

Revised: November 15, 2018 Effective January 1, 2019 Page 56 of 126  Client who is pre- barriers is not sufficient to contemplative achieve symptom or functional regarding engagement improvement without in a higher level of care additional supports  Diagnosis and/or age-related Authorization Length:1 functional deficits and/or year complex medical issues requiring substantial coordination

Revised: November 15, 2018 Effective January 1, 2019 Page 57 of 126 Mental Health Outpatient: Level C SPMI Adult SERVICE DESCRIPTION CRITERIA FOR CONCURRENT REVIEW CRITERIA TRANSITION/ DISCHARGE AUTHORIZATION CRITERIA

Services are designed to Two of the following: Continues to meet admission At least ONE of the following promote recovery and criteria AND at least one of the must be met: rehabilitation for adults with  Covered diagnosis on the following: severe and persistent prioritized list  Documented treatment symptoms of mental illness.  Significant assistance  Capable of additional goals and objectives have These services instruct, assist, required to meet basic symptom or functional been substantially met needs such as housing  Continuing stabilization and support an individual to improvement at this level of and food can occur with discharge build or improve skills that care  Significant PTSD or  Significant cultural and from treatment with have been impaired by these depression symptoms as language barriers impacting medication management symptoms. Comprehensive a result of torture, ability to fully integrate by PCP and/or assessment and treatment ongoing systemic symptom management skills appropriate community planning focus on outcomes oppression, trauma or and there is no more clinically supports and goals with specific multiple losses appropriate service  Individual has achieved symptom or functional interventions described to AND at least two of the improvement in resolving achieve them. Emphasis is following: issues resulting in placed on linkages with other admission to this level of

services and coordination of care  At least one care.  Meets criteria for a hospitalization within the different level of care due past year Services may include: to change in symptoms or  Symptoms related to the function at this level of evaluation and assessment, mental illness result in a care outreach, consultation, case moderate to significant management, counseling, functional impairment

Revised: November 15, 2018 Effective January 1, 2019 Page 58 of 126 medication evaluation and and are only partially management, daily structure controlled and support, skills training,  Risk of harm to self or family education and support, others or risk of harm to self or others that is integrated substance abuse escalated from baseline treatment, supported  Multiple system employment, relapse involvement requiring prevention, hospital diversion, substantial coordination crisis intervention and  Extended or repeated supported housing. crisis episode(s) requiring increased services  Significant current Diagnoses generally covered substance abuse for under this authorization type: which treatment is Schizophrenia; Schizoaffective necessary Disorder; Psychosis, Mood and  Risk of loss of current Anxiety Disorders that are living situation, in an severe and persistent in unsafe living situation, or nature and have serious currently homeless due to symptoms of mental impact on activities of daily illness living  Individual has a marginalized identity Examples Include: which creates barriers to  Individual requires receiving appropriate increased coordination in services, and/or order to meet basic needs individual’s level of such as safety, housing and English language skill food. and/or cultural  Individual’s symptoms are navigation barriers is not partially controlled. sufficient to achieve

Revised: November 15, 2018 Effective January 1, 2019 Page 59 of 126  Client who is pre- symptom or functional contemplative regarding improvement without engagement in a higher additional supports level of care  Diagnosis and/or age-  Additional care related functional deficits coordination linking client and/or complex medical to resources will prevent issues requiring hospitalization. substantial coordination  Intensive Case Management (ICM) client or Assertive Community Treatment (ACT) client who is not ready to engage in additional services

Authorization Length: 1 year

Revised: November 15, 2018 Effective January 1, 2019 Page 60 of 126

Mental Health Outpatient: Level D: Adult Intensive Case Management (ICM) or Transition Age Youth (TAY) SERVICE DESCRIPTION CRITERIA FOR CONCURRENT REVIEW CRITERIA TRANSITION/ DISCHARGE AUTHORIZATION CRITERIA

Services are provided at an Criteria for ICM: Criteria for ICM and TAY: At least ONE of the following intensive level in the home  Covered diagnosis on the must be met: and community with the goal prioritized list Continues to meet admission of stabilizing behaviors and criteria AND at least one of the  Documented treatment symptoms that led to AND at least two of the following: goals and objectives have admission. following: been substantially met   2 or more inpatient  Capable of additional symptom Continuing stabilization can occur with discharge Programs include an array of admissions in the past or functional improvement at year this level of care from treatment with coordinated and integrated medication management  Recent discharge from the  Significant cultural and multidisciplinary services by PCP and/or appropriate State Hospital (within the language barriers impacting designed to address community supports past year) ability to fully integrate  presenting symptoms in a  Civil Commitment or symptom management skills Individual has achieved developmentally appropriate Discharge from the state and there is no more clinically symptom or functional context. These services could hospital within the past appropriate service improvement in resolving issues resulting in include group, individual, year)  Eviction or homelessness is  Residing in an inpatient admission to this level of family, psycho educational likely if level of care is reduced bed or supervised care services, crisis management community residence and  Meets criteria for a and adjunctive services such clinically assessed to be different level of care due as medical monitoring. able to live in a more to change in symptoms or Services include multiple or independent living function at this level of extended treatment visits. situation if intensive care services are provided  Severe deficits in skills needed for community

Revised: November 15, 2018 Effective January 1, 2019 Page 61 of 126 Diagnoses generally covered living as well as a high under this authorization type: degree of impairment due Schizophrenia; Schizoaffective to symptoms of mental illness Disorder; Psychosis, Mood and  Significant PTSD or Anxiety Disorders are severe depression symptoms as a and persistent in nature and result of torture, ongoing have serious impact on systemic oppression, activities of daily living. trauma or multiple losses depression symptoms as a 24/7 telephonic crisis support result of torture, ongoing systemic oppression, is provided by the ICM or TAY trauma or multiple losses team OR at least three of the Services differ from Assertive following: Community Treatment (ACT) in frequency and in 24/7 face-  Intractable, severe major to-face crisis availability symptoms  Significant cultural or Examples Include: linguistic barriers exist  ICM: Adult with severe life  Significant criminal justice skill deficits, secondary to involvement mental health symptoms,  Requires residential with a recent transition placement if intensive from State or Inpatient services are not available Hospitalization requires  Not engaged in services coordination of but deemed at high risk of multidisciplinary services in harm related to their the home. mental illness

Revised: November 15, 2018 Effective January 1, 2019 Page 62 of 126  TAY: Teen or young adult  Severe deficits in skills with persistent psychotic needed for community symptoms requires living as well as a high intensive, in home, care degree of impairment due coordination in order to to symptoms of mental meet treatment, housing, illness and employment needs.  Co-occurring addiction diagnosis Authorization length: 1 year  Risk of loss of current living situation, in an unsafe living situation, or currently homeless due to symptoms of mental illness

Criteria for TAY:  Covered diagnosis on the prioritized list AND at least one of the following:  2 or more inpatient admissions in the past year  Recent discharge from the Youth’s Secure Inpatient Adolescent Program or long term Psychiatric Residential Treatment Services  Residing in an inpatient bed or supervised community residence and

Revised: November 15, 2018 Effective January 1, 2019 Page 63 of 126 clinically assessed to be able to live in a more independent living situation if intensive services are provided  Severe deficits in skills needed for community living as well as a high degree of impairment due to symptoms of mental illness,

OR at least three of the following:  Intractable, severe major symptoms  Significant cultural or linguistic barriers exist  Significant criminal justice involvement  Requires residential placement if intensive services are not available  Not engaged in services but deemed at high risk of harm related to their mental illness  Severe deficits in skills needed for community living as well as a high degree of impairment due

Revised: November 15, 2018 Effective January 1, 2019 Page 64 of 126 to symptoms of mental illness  Co-occurring addiction diagnosis  Risk of loss of current living situation, in an unsafe living situation, or currently homeless due to symptoms of mental illness  Significant PTSD or depression symptoms as a result of torture, ongoing systemic oppression, trauma or multiple losses

Revised: November 15, 2018 Effective January 1, 2019 Page 65 of 126 Mental Health Intensive Outpatient Treatment (I/OP) SERVICE DESCRIPTION CRITERIA FOR AUTHORIZATION CONCURRENT REVIEW TRANSITION/ DISCHARGE CRITERIA CRITERIA Intensive Outpatient provides All the following must be At least one of the following: At least one of the following: stabilization of acute and met: severe mental illness in a  Clinical evidence that an  Concurrent review criteria structured, short term  Mental health diagnosis attempt at therapeutic re- is no longer met treatment setting with the covered by the Oregon entry to a less intensive  The individual is not making intention of returning or Health Plan Prioritized List level of care would result in progress toward treatment connecting the member to of Health Services exacerbation of the goals and there is no their treating community  Mental health condition psychiatric illness to the expectation of progress at provider. that requires a structured degree that continued this level of care despite program with frequent Intensive Outpatient is treatment planning changes Services are provided for an nursing and medical needed  Stepping up to inpatient aggregate between 10 and 19 supervision, intervention  Clinical criteria for facility level of care, or stepping hours a week.  Is not responsive to based Intensive Outpatient down to a lesser intensive treatment provided in a less treatment services are met level of outpatient care is Treatment is provided by a intensive outpatient setting due to continuation of indicated multidisciplinary treatment  Would be at risk to self or presenting DSM behaviors  The documented treatment team, including psychiatric others , and/or would and/or symptoms, or the plan, goals , and objectives and nursing care as part of an experience a significant emergence of new have been substantially active treatment program. deterioration of functioning symptoms, or the met; Treatment also includes if not in an intensive emergence of new and/or  There is a discharge plan coordination and discharge outpatient program previously unidentified DSM with follow-up planning with the community  There is reasonable behaviors and/or symptoms appointments in place prior provider who will be treating expectation that the level of  Persistence of problems to discharge. the client after discharge from care will stabilize and/or that caused the admission Intensive Outpatient. improve the member’s to an extent that continues symptoms and behaviors or to meet the admission Intensive Outpatient is prevent further regression, criteria intended to be alternative to and the member must be hospitalization. Individuals able to participate and

Revised: November 15, 2018 Effective January 1, 2019 Page 66 of 126 may be referred from the benefit from the level of  The member requires community to stabilize a crisis, care requested. frequent nursing and from the emergency room as a  Acute stage symptoms have medical supervision diversion from inpatient, or been stabilized, but could  Emergence of additional from inpatient to transition require a minimum of 3 problems that meet the back into the community with hours of care for a admission criteria supports. minimum of 3 times a week  Active discharge planning to further support begins at admission, and Partial hospitalization services stabilization. continues throughout are generally authorized for 5 treatment – 10 days at a time.  Member is currently involved and cooperating Provider to follow local BHPP with the treatment process pre-authorization process.  Member is not actively participating in treatment and meets one of the following: o Treatment plan and/or discharge goals are reformulated to address the lack of expected progress o There are measurable indicators that the member is progressing toward active engagement in treatment.

Revised: November 15, 2018 Effective January 1, 2019 Page 67 of 126 Mental Health Partial Hospitalization SERVICE DESCRIPTION CRITERIA FOR AUTHORIZATION CONCURRENT REVIEW TRANSITION/ DISCHARGE CRITERIA CRITERIA Partial Hospitalization All the following must be At least one of the following: At least one of the following: provides stabilization of acute met: and severe mental illness in a  Clinical evidence that an  Concurrent review criteria structured, short term  Mental health diagnosis attempt at therapeutic re- is no longer met treatment setting with the covered by the Oregon entry to a less intensive  The individual is not making intention of returning or Health Plan Prioritized List level of care would result in progress toward treatment connecting the member to of Health Services exacerbation of the goals and there is no their treating community  Mental health condition psychiatric illness to the expectation of progress at provider. that requires a structured degree that continued this level of care despite program with frequent partial hospitalization is treatment planning changes Services are provided for an nursing and medical needed  Stepping up to inpatient aggregate of services greater supervision, intervention  Persistence of problems level of care, or stepping than 20 hours per week.  Is not responsive to that caused the admission down to a lesser intensive treatment provided in a less to an extent that continues level of outpatient care is Treatment is provided by a intensive outpatient setting to meet the admission indicated multidisciplinary treatment  Would be at risk to self or criteria  The documented treatment team, including psychiatric others if not in a partial  Emergence of additional plan, goals , and objectives and nursing care as part of an hospital program problems that meet the have been substantially active treatment program.  Presence of or regression admission criteria met; Treatment also includes towards acute stage  Member is currently  There is a discharge plan coordination and discharge symptoms that do not meet involved and cooperating with follow-up planning with the community the criteria for 24 hour with the treatment process appointments in place prior provider who will be treating inpatient treatment, but  Member is not actively to discharge. the client after discharge from could require an aggregate participating in treatment Partial Hospital. of services greater than 20 and meets one of the hours per week following: Partial hospitalization is  Substance use or o Treatment plan and/or intended to be alternative to intoxication has been ruled discharge goals are hospitalization. Individuals out as a primary cause of reformulated to address

Revised: November 15, 2018 Effective January 1, 2019 Page 68 of 126 may be referred to partial presenting mental or the lack of expected hospitalization from the behavioral symptoms progress community to stabilize a crisis, o There are measurable from the emergency room as a indicators that the diversion from inpatient, or member is progressing from inpatient to transition toward active back into the community with engagement in supports. treatment.

Partial hospitalization services are generally authorized for 7 – 10 days at a time.

Provider to follow local BHPP pre-authorization process.

Revised: November 15, 2018 Effective January 1, 2019 Page 69 of 126 Psychiatric Day Treatment Services Youth SERVICE DESCRIPTION CRITERIA FOR AUTHORIZATION CONCURRENT REVIEW CRITERIA TRANSITION/ DISCHARGE CRITERIA Psychiatric Day Treatment Criteria for Early Childhood Must meet both of the At least one of the following: Services (PDTS) is a (ages 0-6) and School-Age and following: comprehensive, inter- Adolescents: All must be met:  Concurrent review criteria disciplinary, non-residential,  Capable of additional no longer met or youth community-based program  Mental health diagnosis symptom or functional meets criteria for a higher consisting of psychiatric covered by the Oregon improvement at this level of level of care treatment, family treatment Health Plan Prioritized List care  Youth has met treatment and therapeutic activities of Health Services and be  Active engagement of the goals and is able to function integrated with an accredited paired with PDTS that home school district in successfully in school or education program would be the focus of identification of education appropriate educational treatment placement at discharge placement Services include 24 hour,  Mental health symptoms  Youth has practiced and seven days a week treatment requiring active mental And three of the integrated new skills responsibility for admitted health treatment in order to following: sufficiently to utilize them Youth and on-call capability at improve functioning  Acuity, severity and in lower level of care all times to respond directly or  Resources available in the frequency of psychiatric  A school placement has by referral to the treatment school and community have symptoms at admission been identified by the needs of admitted Youth. been tried and are not have not decreased or home district prior to meeting the youth’s stabilized; transition Admission not solely for the treatment needs  Emergence of new  Youth’s mental health purpose of placement or at psychiatric symptoms needs can be met a lower the convenience of the family, Additional Criteria for Early requiring day treatment level of service the provider or other Youth Childhood. One of the level of care;  Youth requires 24-hour, serving agencies. following:  Attempts at re-entry into a seven day a week active  Identified mental health less restrictive day care, mental health treatment Initial Authorization: 90 days symptoms acuity and preschool or school setting under the direction of a intensity impacting the have resulted in psychiatrist (Psychiatric Continued Stay: 30 days Youth or youth’s ability to exacerbated or re-

Revised: November 15, 2018 Effective January 1, 2019 Page 70 of 126 function in a day care or emergence of symptoms of Residential Treatment preschool setting the mental health illness Services)  Complex developmental that can’t be mitigated with  Family withdraws the Youth presentation impacting one school and community from services or chooses or more of the following supports not to engage in services areas:  Individualized plan of care  Youth and/or family is not o Social with specific interventions, fully able to engage in o Emotional and Youth/adolescent’s services or has achieved o Neurobiological response to the maximum benefit o Physical and/or interventions and progress o Sensory Development toward treatment goals or Additional Consideration: reflects that treatment  For high school students, School-Age and Adolescents. goals can’t be achieved in a timing of transition to Both of the following: less restrictive setting minimize the negative  A transition plan has been impact of academic  Identified mental health developed and has a progress related to symptoms acuity and timeline for implementation achieving credits should be intensity impact the Youth including active Child and taken into consideration or youth’s ability to function Family Team meetings or in a school setting interdisciplinary review  A milieu environment along meetings and engagement with psychiatric support are with school, community documented as needed and resources, and natural are not available through supports intensive community-based  Ongoing active engagement services or is a diversion or of home school district in stepdown from psychiatric identification of educational residential treatment placement at discharge

Revised: November 15, 2018 Effective January 1, 2019 Page 71 of 126 Psychiatric Residential Treatment Services Youth SERVICE DESCRIPTION CRITERIA FOR AUTHORIZATION CONCURRENT REVIEW TRANSITION/ DISCHARGE CRITERIA CRITERIA

Behavioral health care To be considered for Concurrent review conducted Discharge occurs when: program certified under OAR admission, the individual must every 14 days. To meet criteria 309-032-1540 to provide 24- meet the following criteria: for continued stay, the Youth  Youth/adolescent has met hour, 7 day a week active must be capable of additional treatment goals and is able mental health treatment  serious emotional symptom or functional to function successfully in under the direction of a disturbance or mental improvement at this level of the home, school and psychiatrist. health condition that care and the interdisciplinary community; and requires active psychiatric record must document:  Youth’s mental health Primary diagnoses not treatment 24 hours/7 days needs can be met a lower “paired” with PRTS on the a week;  The PRTS provider has level of service; or Oregon Health Plan Prioritized  resources available in the measurable indicators of  the family withdraws the List of Health Services and community do not meet the whether the client’s mental Youth from services; or generally not considered for Youth’s treatment needs health symptoms that led  the family chooses not to authorization:  behaviors responsive to to the admission, or as engage in services; or  Attention Deficit PRTS include active identified post-admission,  Youth has achieved Hyperactivity Disorder psychosis and risk of harm are responding to the maximum benefit; or  Adjustment Disorder to self or others treatment plan. This may be  the Child and Family Team  Substance Use Disorder  mental health condition at a reflected in a change in (if involved in Wraparound)  Intellectual Developmental level of acuity or severity CASII or ECSII score (within or treatment team Disorder that it is impacting all areas a domain or overall) determines that the Youth of life and functioning  Documentation is obtained and/or family is not fully  requires intensive from the PRTS provider of able to engage in services psychiatric oversight and ongoing discharge planning and recommends discharge. active mental health related to the discharge treatment in order to criteria in the Plan of Care. improve functioning  The client’s record documents any attempts at

Revised: November 15, 2018 Effective January 1, 2019 Page 72 of 126 re-entry into the Contraindications for PRTS: community (e.g. overnight or day passes) that have  Diagnoses not found resulted in exacerbation or responsive to/ best practice re-emergence of symptoms to treat in PRTS: of the mental illness and o Reactive Attachment cannot be mitigated with Disorder community supports. o Oppositional Defiant  The treatment plan Disorder documents that treatment o Conduct Disorder goals cannot be achieved in a less restrictive setting.  Behaviors, independent of a  Continued stay is not due to covered mental health the convenience of family diagnosis, not found to be or other entities and is not responsive to PRTS: solely for placement o Bullying  The Child and Family Team o Physical aggression and/or treatment team o Sexual offending determines that the Youth o Property destruction requires a secure inpatient o Fire setting program such as Secure o Truancy Youth’s Inpatient Program o Running away (SCIP) or Secure Adolescent o Pattern of defiant Inpatient Program (SAIP) behavior and the client has been accepted and is on the wait To be considered for list. admission to PRTS, the Youth/adolescent must meet all of the following criteria:

 have a mental health diagnosis covered by the

Revised: November 15, 2018 Effective January 1, 2019 Page 73 of 126 Oregon Health Plan Prioritized List of Health Services and paired with PRTS that would be the focus of treatment; and  admission not solely for purposes of placement or at the convenience of the family, the provider or other Youth serving agencies; and

 Level of Service Intensity Determination outcome of Level 5 or higher; and  written recommendation from the treating psychiatrist indicating: 1) the need and/or reason for a residential level of care; 2) why a less acute level of care would not be sufficient to address the psychiatric need; 3) the benefit to the Youth and family from this recommended treatment episode; and  Approved Certificate of Need (CONS) completed prior to admission which certifies the need for this level of care

Revised: November 15, 2018 Effective January 1, 2019 Page 74 of 126 Psychological Testing SERVICE DESCRIPTION CRITERIA FOR AUTHORIZATION CONCURRENT REVIEW TRANSITION/ DISCHARGE CRITERIA CRITERIA

Psychological testing is Must meet all of the following: Concurrent review is required A written integrated defined as “a measurement if the psychologist will exceed psychological assessment procedure for assessing  Primary purpose of testing the number of hours pre- report must be submitted and psychological characteristics in is to obtain diagnostic authorized. This will only be include the following: which a sample of an clarification of a covered reviewed in exceptional needs examinee’s behavior is mental health diagnosis; cases where circumstances  Clinical interview obtained and subsequently specifically, to address a justify need for additional  Summary of collateral evaluated and scored using a particular diagnostic and/or hours of testing and the information, history and standardized process” treatment question(s) which following must be met: background information; (American Psychological cannot be answered referral question Association, 2000). through usual means of  The psychologist must  Summary of all records Psychological testing requires clinical interview and provide an explanation of reviewed, including any the application of appropriate collateral data review why additional hours and previous psychological normative data for (including review of any testing are needed and why testing results interpretation or classification previous psychological continued authorization is  Summary of any and may be used to guide testing). requested. (ie. the member exceptional issues that differential diagnosis in the  Test results are expected to is not tolerating testing so arose during the testing treatment of psychiatric significantly impact the the testing needs to be process (i.e., why additional disorders. patient’s treatment, done in shorter periods of time was needed for thereby leading to time over a longer time testing) Psychological Testing includes improvement in the span).  Tests administered; results psychodiagnostic assessment patient’s mental health  Pre-authorization of of each test administered of emotionality, intellectual condition and/or additional hours of testing  Clinical formulation abilities, personality and functioning. is required.  Diagnosis and diagnostic psychopathology, e.g., WAIS,  Patient has had a full justification including rule Rorschach, MMPI. mental health assessment out of diagnoses as they Psychological Testing must completed by an approved pertain to referral question consist of face-to-face behavioral healthcare

Revised: November 15, 2018 Effective January 1, 2019 Page 75 of 126 psychological assessment of provider within the six  Specific answer(s) to member and include the months prior to the referral question(s) following: clinical interview request.  Clear and individualized with member and collateral  Request for testing must be clinical recommendations sources; integration of made by a behavioral by the authorized collateral information, healthcare provider. psychologist including previous  Medical conditions have It is recommended that a psychological or been ruled out as a primary debriefing of results and neuropsychological testing, as cause of the mental health assessment is provided to well as history and condition and/or are not client, guardian, and background information; tests the primary focus of testing appropriate treatment administered must directly (or, in cases where a providers. address referral question; and medical condition is a must primarily include tests primary contributing factor, beyond self-report measures the physical health plan will and most often should include be engaged in discussion psychodiagnostic assessment concerning payment for of emotionality, intellectual psychological or abilities, personality and neuropsychological testing) psychopathology. Exclusion Criteria (one or It is also recommended that the member be seen by a more): Licensed Medical Professional  Testing is for educational who also recommends testing (IEP/ Learning Disorders), and the reason(s) why. vocational, or legal purposes (including court- Provider requirements: The ordered testing) provider is a licensed doctoral  Testing is to assist in level psychologist or determining eligibility for psychiatrist who is adequately any kind of services (i.e., trained in the administration vocational rehab, disability, IEP, etc.)

Revised: November 15, 2018 Effective January 1, 2019 Page 76 of 126 and interpretation of  Testing is conducted as a psychological instruments. screening tool or part of an initial evaluation. Authorization: Prior  Testing is requested by authorization must be patient for personal obtained prior to the start of interest. services and must not exceed  Medical condition(s) have the allowable amount based on identified hours to been determined to be a complete testing primary cause of the mental health condition and/or are not the primary focus of testing (in which case the physical health plan would be responsible for providing requested psychological and/or neuropsychological testing)

Revised: November 15, 2018 Effective January 1, 2019 Page 77 of 126 Respite Services Youth SERVICE DESCRIPTION CRITERIA FOR AUTHORIZATION CONCURRENT REVIEW TRANSITION/ DISCHARGE CRITERIA CRITERIA Respite services are provided to To be considered for admission, Crisis respite is initially Discharge occurs when: Youth and their families for the individual must meet the authorized for 1-7 days temporary relief from care giving in following criteria: to assist with  the Youth/adolescent order to maintain a stable and safe  engaged with an identified stabilization. and family have living environment. Respite treatment provider that is benefited from respite services are often utilized to avoid requesting authorization of On-going authorization services and the youth the need for an out of home respite as an intervention; and for crisis respite is is no longer at risk of placement or a higher of level of  does not meet the criteria for provided for an losing their current care. 24-hour acute care but needs additional 1-7 days as community setting; or temporary, structured, indicated by a lack of  the Youth/adolescent Crisis or planned respite services is supportive, non-medical, safe stabilization either of the is in need of a higher provided in either a licensed 24 environment due to an Youth/adolescent, level of care. hour facility or foster home certified exacerbation or increase of caregiver or home  Exceeding the standard and licensed by a contracted mental difficult, unsafe, destructive environment. authorization for this health provider. Services and behaviors due to family stress or intervention and there supports during the respite stay conflict or caregiver stress; and Planned respite, when is not documentation include supervision, structure,  natural and informal supports part of an on-going supporting ongoing stabilization and support. (such as extended family, treatment plan or Plan of medical necessity. friends, neighbors, church Care is authorized for a Respite is not authorized solely for members, etc) have been total of 14 days in a 6 Respite can be an ongoing the convenience of the family or the explored and are not available month period. and/or episodic service service providers. or adequate; and based on the clinical  symptoms and/or behaviors are Adjustments to the needs of the Crisis Respite is authorized for up to not due to substance authorization are Youth/adolescent and 7 days abuse/intoxication, a medical requested through the family. condition, or other circumstance Child and Family Team.

Revised: November 15, 2018 Effective January 1, 2019 Page 78 of 126 Contact the local BHPP for Planned not covered by the mental Respite initial and continued stay health benefit. authorization

Revised: November 15, 2018 Effective January 1, 2019 Page 79 of 126 Respite Services Adult SERVICE DESCRIPTION CRITERIA FOR AUTHORIZATION CONCURRENT REVIEW TRANSITION/ DISCHARGE CRITERIA CRITERIA Respite services are short- To be considered for admission, the Continued stay criteria Discharge criteria include: term environmental and individual must meet the following includes: symptom stabilization criteria:  evidence that the mental related to mental health  persistence of problems health symptoms have symptoms.  is unable to care for basic needs at that caused the stabilized, diminished or current living situation due to the admission to a degree resolved; and Respite services are impact of the psychiatric illness on that continues to meet  there is no longer evidence provided in a 24-hour behavior and functioning; and the admission criteria; of a risk of hospitalization; licensed facility .Services  does not meet the criteria for 24- or and must be reasonably hour acute care but needs a  the emergence of  the improved mental health expected to improve or temporary, structured, supportive additional problems status allows the individual maintain the condition and environment while mental health that meet the admission to provide for their own functional level of the needs are actively addressed; and criteria; or safety and basic needs; and individual and prevent  symptoms and/or behaviors are  discharge planning  resources and a support relapse or hospitalization. not due to substance and/or attempts at re- system exist in the abuse/intoxication, a medical entry into the community that are Services include condition, or other circumstance community have adequate to provide the assessment, supervision, not covered by the mental health resulted in or would level of support and structure and support, and benefit; and. result in an supervision needed for limited care coordination  does not have an unstable medical exacerbation of the safety, self-care and secondary to external condition requiring medical mental health effective treatment. mental health case supervision; and symptoms to the degree management, medication  is not experiencing acute it would result in the administration, and room withdrawal symptoms. need for hospitalization and board.

Revised: November 15, 2018 Effective January 1, 2019 Page 80 of 126 Homelessness is not an Additionally, the individual may meet exclusion criteria as long as one or more of the following criteria: the primary reason for respite is due to a  requires stabilization due to a psychiatric or mental health recent medication adjustment or a condition. Respite should supportive environment during a not be used solely for the medication change purpose of housing or  is unstable in current living placement. situation due to medication non- compliance and is willing to take Projected length of stay is medications as prescribed while in generally 3-7 days respite  feels unsafe towards self due to Contact local BHPP for current psychiatric condition initial and continued stay and/or current stressors and is authorization length of stay willing to contract for safety while in respite  requires stabilization following a hospital discharge while community-based services are being arranged

Individuals may be excluded from authorization based on recent history of physical assault, homicidal behavior, arson, sexual offenses, weapon possession, anti-social personality or other factors that would make the individual a high-risk in this environment.

Revised: November 15, 2018 Effective January 1, 2019 Page 81 of 126 Subacute Services Youth SERVICE DESCRIPTION CRITERIA FOR AUTHORIZATION CONCURRENT REVIEW TRANSITION/ DISCHARGE CRITERIA CRITERIA Subacute services, for Youth All the following must be The following must be At least one of the following: ages 5-17 require 24-hour met: met: secure and protected,  Treatment team concurs that  Documented treatment medically staffed and  Been evaluated by a continued stabilization is goals and objectives have psychiatrically supervised qualified mental health needed and there is an active been substantially met treatment environment with professional, other licensed transition plan from this level  Individual has achieved 16-hour skills nursing, clinician, or medical of care, AND symptom or functional structured treatment milieu professional and improvement in resolving and 3:1 Youth to staff ratio. demonstrates At least one of the following: issues resulting in symptomatology consistent admission to this level of Initial Authorization: Until with current DSM 5  acuity, severity and care next business day diagnosis, requiring and can frequency of  Meets criteria for a reasonably be expected to psychiatric symptoms different level of care due Continued Stay authorization: respond to therapeutic at admission have not to change in symptoms or 2 business days. intervention decreased or stabilized function at this level of care  Consent has been obtained  emergence of new  OP treatment services have by Youth's legal guardian. If psychiatric symptoms been initiated that will no legal guardian is requiring continued allow for the current available, DHS has been evaluation and treatment needs to safely contacted, has emergency treatment be supported in the custody and has provided  a severe reaction to community. consent for admission medication or the  Youth/ adolescent cannot be need for further safely maintained and monitoring and effectively treated at a less adjustment of dosage intensive level of care that requires 24 hour medical supervision

Revised: November 15, 2018 Effective January 1, 2019 Page 82 of 126  Youth/ adolescent has a place to live and/or the community team is actively addressing placement needs which will be resolved within the two weeks of the subacute stay

At least two of the following must be met:  Is acutely ill due to a primary psychiatric illness and requires psychiatric care for evaluation and treatment  Co-occurring presentation of substance use and psychiatric symptoms and has been medically cleared or completed Detox protocol and the psychiatric symptoms are the reason for the admission  Deemed to be at high risk of harm to self or others as evidenced by the following: o Presents with thoughts of suicide with a possible plan or o Has recently attempted suicide or engaged in significant self-harm

Revised: November 15, 2018 Effective January 1, 2019 Page 83 of 126 o Thoughts and possible plans of homicide or harming others o Been assaultive towards others and is judged to be at continued risk of violence to others o Has severe impulsivity resulting in harm to self or others including significant risk-taking behaviors  Need for a mental health assessment or evaluation that cannot be safely provided in a less restrictive setting

Contraindications to Subacute:  Requires 1:1 staffing  Requires daily face-to-face psychiatric evaluation and management  Requires chemical or mechanical restraint  Primary presentation related to criminal behavior  Substance use disorder without co-occurring psychiatric diagnosis

Revised: November 15, 2018 Effective January 1, 2019 Page 84 of 126  Medically unstable or requiring medical management including eating disorders that are not stable or require oversight by a registered dietician or unstable or labile diabetes  Major medical or surgical illness that prevents active participation in a treatment program such as: Ongoing IV Therapy; Cardiac telemetry monitoring; Continuous oxygen or support equipment or ongoing suctioning

Revised: November 15, 2018 Effective January 1, 2019 Page 85 of 126 Substance Use Disorder Practice Guidelines

Substance Use Disorder Outpatient - ASAM Levels 1.0, 2.1, and 2.5 Youth SERVICE DESCRIPTION Outpatient services can be delivered in a variety of settings and generally provide professionally directed screening, evaluation, treatment, and ongoing recovery and disease management services.

Therapies offered in outpatient involve skilled treatment services, which may include individual and group counseling, motivational enhancement, family therapy, educational groups, occupational and recreational therapy, psychotherapy, addiction pharmacotherapy, or other therapies. Motivational enhancement and engagement strategies are used in preference to confrontational approaches. For patients with mental health conditions, the issues of psychotropic medication, mental health treatment, and their relationship to substance use and addictive disorders are addressed as the need arises.

While the services provided the outpatient levels of care are generally the same, the number of hours per week varies. Such services are provided in an amount, frequency, and intensity appropriate to the patient’s multidimensional severity and level of function. Levels of care can be fluid where patients move between levels of care based on their needs. The ASAM Criteria outlines the following services hours for youth in outpatient:

Level 1.0 Outpatient: Fewer than 6 hours per week Level 2.1 Intensive Outpatient: 6-19 hours per week Level 2.5 Partial Hospitalization/ Day Treatment: 20 or more hours per week

Outpatient Addictions and Mental Health services may be offered in any appropriate setting that meets state licensure or certification criteria, including OARs 309-019-0100 through 309-019-0220.

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Criteria for Authorization To be appropriate for outpatient services, the individual must meet diagnostic criteria in the DSM-5 for a Substance Use Disorder of at least Mild or Moderate severity and meet ASAM criteria for the level of care provided.

For co-occurring capable and co-occurring enhanced programs, the patient also meets DSM-5 criteria for a covered mental health disorder.

ASAM Dimension Dimension 2: Dimension 3: Dimension 4: Dimension 5: Dimension Level of 1: Acute Biomedical Emotional/ Behavioral Readiness to Relapse, 6: Care Intoxication Conditions or Cognitive Conditions Change Continued Recovery and/or and and Complications Use or Environme Withdrawal Complications Continued nt Problem Potential Level 1.0 No withdrawal None or very Meets all of the following: Willing to Able to maintain Family and Outpatient risk stable, or is A.) the adolescent is not at engage in abstinence or environment receiving risk of harm, B.) there is treatment, and control use and can support concurrent minimal interference, C.) is at least pursue recovery recovery monitoring Minimal to mild contemplating goals with with limited impairment, D.) the change, but minimal support assistance adolescent is experiencing needs minimal current difficulties motivating and with activities of daily living, monitoring but there is significant risk strategies of deterioration, E.) the adolescent is at minimal imminent risk, which predicts a need for some monitoring or interventions

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ASAM Dimension 1: Dimension 2: Dimension 3: Dimension Dimension Dimension Level of Acute Biomedical Emotional/ Behavioral 4: 5: Relapse, 6: Recovery Care Intoxication Conditions or Cognitive Conditions Readiness Continued Environmen and/or and and Complications to Change Use or t Withdrawal Complication Continued s Problem Potential Level 2.1 Experiencing None or very Meets one or more of the Requires Significant risk Adolescent’s Intensive minimal stable, or following: A.) The close of relapse or environment is Outpatient withdrawal, or is distracting from adolescent is at low risk of monitoring continued use, impeding his at risk of treatment at a harm, and he or she is safe and support or continued or her withdrawal less intensive between sessions, B.) Mild several times problems and recovery, and level of care. interference requires the a week to deterioration adolescent Such problems intensity of this level of care promote in level of requires close are manageable to support treatment progress functioning. monitoring at Level 2.1 engagement, C.) Mild to through the Has poor and support to moderate impairment, but stages of prevention overcome that can sustain responsibilities, change skills and barrier D.) The adolescent is because of needs close experiencing mild to variable monitoring moderate difficulties with treatment and support activities of daily living, and engagement, requires frequent or no interest monitoring or in getting interventions, E.) The assistance adolescent’s history (combined with the present situation) predicts the need for frequent monitoring or interventions

Revised: November 15, 2018 Effective January 1, 2019 Page 88 of 126 ASAM Level Dimension Dimension 2: Dimension 3: Dimension Dimension Dimension 6: of Care 1: Acute Biomedical Emotional/ Behavioral 4: 5: Relapse, Recovery Intoxicatio Conditions or Cognitive Readiness Continued Environment n and/or and Conditions and to Change Use or Withdrawa Complications Complications Continued l Problem Potential Level 2.5 Experiencing None or stable, One or more of the Requires a High risk of Adolescent’s Partial mild or distracting following: A.) The near-daily relapse or environment Hospitalization withdrawal, from treatment adolescent is at low risk of structured continued renders / Day or is at risk of at a less harm, and he or she is safe program to use, or recovery Treatment withdrawal intensive level of overnight, B.) Moderate promote continued unlikely without care. Such interference requires the progress problems and near-daily problems are intensity of this level of through the deterioration monitoring and manageable at care to support treatment stages of in level of support, or Level 2.5 engagement, C.) Moderate change functioning. frequent relief impairment, but can because of Has minimal from his or her sustain responsibilities, D.) little prevention home The adolescent is treatment skills and environment experiencing moderate engagement needs near- difficulties with activities or escalating daily of daily living and requires use and monitoring near-daily monitoring or impairment, and support interventions, E.) The or no adolescent’s history awareness of (combined with the the role that present situation) predicts substances the need to near-daily pay in his or monitoring or her present interventions problems

Revised: November 15, 2018 Effective January 1, 2019 Page 89 of 126 Concurrent Review Criteria It is appropriate to retain the patient at the present level of care if one or more of the following criteria are met:  The patient is making progress, but has not yet achieved the goals articulated in the individualized treatment plan. Continued treatment at the present level of care is assessed as necessary to permit the patient to continue to work toward his or her treatment goals; or  The patient is not yet making progress but has the capacity to resolve his or her problems. He or she is actively working on the goals articulated in the individualized treatment plan. Continued treatment at the present level of care is assessed as necessary to permit the patient to continue to work toward his or her treatment goals; and/or  New problems have been identified that are appropriately treated at the present level of care. The new problem or priority requires services, the frequency and intensity of which can only safely be delivered by continued stay in the current level of care. This level is the least intensive at which the patient’s new problems can be addressed effectively

Transition/ Discharge Criteria It is appropriate to transfer or discharge the patient from the present level of care if he or she meets one of the following criteria:  The patient has achieved the goals articulated in his or her individualized treatment plan, thus resolving the problem(s) that justified admission to the current level of care; or  The patient has been unable to resolve the problem(s) that justified admission to the present level of care, despite amendments to the treatment plan. The patient is determined to have achieved the maximum possible benefit from engagement in services at the current level of care. Treatment at another level of care (more or less intensive) in the same type of service, or discharge from treatment, is therefore indicated; or  The patient has demonstrated a lack of capacity due to diagnostic or co-occurring conditions that limit his or her ability to resolve his or her problem(s). Treatment at a qualitatively different level of care or type of service, or discharge from treatment, is therefore indicated; or  The patient has experienced an intensification of his or her problem(s), or has developed a new problem(s), and can be treated effectively only at a more intensive level of care

Revised: November 15, 2018 Effective January 1, 2019 Page 90 of 126 Substance Use Disorder Outpatient - ASAM Levels 1.0 (opioid treatment program and outpatient), 2.1, and 2.5 Adult Service Description Outpatient services can be delivered in a variety of settings and generally provide professionally directed screening, evaluation, treatment, and ongoing recovery and disease management services.

Therapies offered involve skilled treatment services, which may include individual and group counseling, motivational enhancement, family therapy, educational groups, occupational and recreational therapy, psychotherapy, addiction pharmacotherapy, or other therapies. Acupuncture related to treatment of a substance use disorder may also be provided by qualified professionals. Motivational enhancement and engagement strategies are used in preference to confrontational approaches. For patients with mental health conditions, the issues of psychotropic medication, mental health treatment, and their relationship to substance use and addictive disorders are addressed as the need arises.

“Opioid Treatment Services” is an umbrella term that encompasses a variety of pharmacological and non-pharmacological treatment modalities. The term is intended to broaden understandings of opioid treatments to include all medications used to treat opioid use disorders and the psychosocial services that are offered concurrently with these pharmacotherapies. Pharmacological agents include opioid agonist medications such as methadone and buprenorphine, and opioid antagonist medications such as naltrexone.

Such services are provided in an amount, frequency, and intensity appropriate to the patient’s multidimensional severity and level of function. Levels of care can be fluid where patients move between levels of care based on their needs. The ASAM Criteria outlines the following services hours for adults in outpatient:

Level 1.0 Outpatient: Fewer than 9 hours per week Level 2.1 Intensive Outpatient: 9-19 hours per week Level 2.5 Partial Hospitalization/ Day Treatment: 20 or more hours per week

Outpatient Addictions and Mental Health services may be offered in any appropriate setting that meets state licensure or certification criteria, including OARs 309-019-0100 through 309-019-0220. Opioid Treatment Programs must meet Federal and State regulations, including 42 CFR 8.12 and OARs 410-020-0000 through 410-020-0085.

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Typically Opioid Treatment Services are provided in an outpatient specialty addictions setting. Patients receiving Level 2 (Intensive Outpatient or Day Treatment) or Level 3 (Residential) substance use and co-occurring treatment can be referred to, or be concurrently enrolled in, an Opioid Treatment Program. Opioid Treatment Services can be provided with appropriate collaborations across different settings and at many levels of care, depending on the patient centered assessment findings in Dimensions 1-6, and the patient’s recovery-oriented goals.

Criteria for Authorization To be appropriate for outpatient services, the individual must meet diagnostic criteria in the DSM-5 for a Substance Use Disorder of at least Mild or Moderate severity and meet ASAM criteria for the level of care provided. For co-occurring capable and co-occurring enhanced programs, the patient also meets DSM-5 criteria for a covered mental health disorder.

Considerations for Partial Hospitalization/ Day Treatment: Direct admission to Level 2.5 is advisable for the patient who meets specifications in Dimension 2 (if any biomedical conditions or problems exist)and Dimension 3 (if any emotional, behavioral, or cognitive conditions or problems exist), as well as in at least one of Dimensions 4, 5 or 6. Transfer to a Level 2.5 program is advisable for the patient who has met the essential treatment objectives at a more intensive level of care and requires the intensity of services provided at level 2.5 in at least one of Dimensions 4, 5 or 6. A patient also may be transferred to Level 2.5 from a Level 1 or Level 2.1 program when the services provided at Level 1 have proved insufficient to address the patient’s needs or when those services have consisted of motivational interventions to prepare the patient for participation in a more intensive level of service, for which he or she now meets the admissions criteria

Considerations for Opioid Treatment Services (OTP): To be appropriate for OTP, the individual must meet diagnostic criteria in the DSM-5 for an Opioid Use Disorder of mild, moderate, or severe severity and meet ASAM criteria for Opioid Treatment Program Level 1.0. Patients receiving Level 2 (Intensive Outpatient or Day Treatment) or Level 3 (Residential) substance use and co-occurring treatment can be referred to, or be concurrently enrolled in, an Opioid Treatment Program. Opioid Treatment Services can be provided with appropriate collaborations across different settings and at many levels of care, depending on the patient centered assessment findings in Dimensions 1-6, and the patient’s recovery-oriented goals.

Revised: November 15, 2018 Effective January 1, 2019 Page 92 of 126 ASAM Level Dimension 1: Dimension 2: Dimension 3: Dimension Dimension 5: Dimension 6: of Care Acute Biomedical Emotional/ 4: Relapse, Recovery Intoxication Conditions Behavioral or Readiness Continued Environment and/or and Cognitive to Change Use or Withdrawal Complications Conditions and Continued Complications Problem Potential Opioid Physiologically None or None or manageable Ready to At high risk of Recovery Treatment dependent on manageable in an outpatient change the relapse or environment is Program (OTP) opioids and with outpatient structured negative continued use supportive Level 1.0 requires OTP to medical environment effects of without OTP and/or the prevent monitoring opioid use, and structured patient has skills withdrawal but is not therapy to to cope ready for total promote abstinence treatment from illicit progress prescription or non- prescription drug use

Revised: November 15, 2018 Effective January 1, 2019 Page 93 of 126 ASAM Level Dimension 1: Dimension Dimension 3: Dimension Dimension 5: Dimension 6: of Care Acute 2: Emotional/ 4: Relapse, Recovery Intoxication Biomedical Behavioral or Readiness Continued Environment and/or Conditions Cognitive to Change Use or Withdrawal and Conditions and Continued Complicatio Complications Problem ns Potential Level 1.0 Not None or very None or very stable, Ready for Able to maintain Recovery Outpatient experiencing stable, or is or is receiving recovery but abstinence or environment is significant receiving concurrent mental needs control use supportive withdrawal, or concurrent health monitoring motivating and/or addictive and/or the at minimal risk medical and behaviors and patient has skills of severe monitoring monitoring pursue recovery cope withdrawal. strategies to or motivational Manageable at strengthen goals with Level 1- WM readiness. Or minimal support (see Withdrawal needs ongoing Management monitoring Criteria) and disease management. Or high severity in this dimension but not in other dimensions. Needs Level 1 motivational enhancement strategies

Revised: November 15, 2018 Effective January 1, 2019 Page 94 of 126 ASAM Level Dimension 1: Dimension Dimension 3: Dimension Dimension 5: Dimension 6: of Care Acute 2: Emotional/ 4: Relapse, Recovery Intoxication Biomedical Behavioral or Readiness Continued Environment and/or Conditions Cognitive to Change Use or Withdrawal and Conditions and Continued Complicatio Complications Problem ns Potential Level 2.1 Minimal risk of None or not a Mild severity, with Has variable Intensification of Recovery Intensive severe distraction potential to distract engagement addiction or environment is Outpatient withdrawal, from from recovery; needs in treatment, mental health not supportive, manageable at treatment. monitoring ambivalence, symptoms but with Level 2-WM (see Such or a lack of indicate a high structure and withdrawal problems are awareness of likelihood of support, the management manageable the substance relapse or patient can cope criteria) at Level 2.1 use or mental continued use or health continued problem, and problems requires a without close structured monitoring and program support several several times times per week a week to promote progress through the stages of change

Revised: November 15, 2018 Effective January 1, 2019 Page 95 of 126 ASAM Level Dimension 1: Dimension Dimension 3: Dimension Dimension 5: Dimension 6: of Care Acute 2: Emotional/ 4: Relapse, Recovery Intoxication Biomedical Behavioral or Readiness Continued Environment and/or Conditions Cognitive to Change Use or Withdrawal and Conditions and Continued Complicatio Complications Problem ns Potential Level 2.5 Partial Moderate risk of None or not Mild to moderate Has poor Intensification of Recovery Hospitalization/ severe sufficient to severity, with engagement addiction or environment is Day Treatment withdrawal distract from potential to distract in treatment, mental health not supportive, manageable at treatment, from recovery; needs significant symptoms, but with Level 2-WM (see Such stabilization ambivalence, despite active structure and withdrawal problems are or a lack of participation in a support and management manageable awareness of Level 1 or 2.1 relief from the criteria) at Level 2.5 the substance program, home use or mental indicates a high environment, health likelihood of the patient can problem, relapse or cope requiring a continued use or nearly-daily continued structured problems program or without near- intensive daily monitoring engagement and support services to promote progress through the stages of change

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Concurrent Review Criteria It is appropriate to retain the patient at the present level of care if one or more of the following criteria are met:  The patient is making progress, but has not yet achieved the goals articulated in the individualized treatment plan. Continued treatment at the present level of care is assessed as necessary to permit the patient to continue to work toward his or her treatment goals; or  The patient is not yet making progress but has the capacity to resolve his or her problems. He or she is actively working on the goals articulated in the individualized treatment plan. Continued treatment at the present level of care is assessed as necessary to permit the patient to continue to work toward his or her treatment goals; and/or  New problems have been identified that are appropriately treated at the present level of care. The new problem or priority requires services, the frequency and intensity of which can only safely be delivered by continued stay in the current level of care. This level is the least intensive at which the patient’s new problems can be addressed effectively

Transition/ Discharge Criteria It is appropriate to transfer or discharge the patient from the present level of care if he or she meets one of the following criteria:  The patient has achieved the goals articulated in his or her individualized treatment plan, thus resolving the problem(s) that justified admission to the current level of care; or  The patient has been unable to resolve the problem(s) that justified admission to the present level of care, despite amendments to the treatment plan. The patient is determined to have achieved the maximum possible benefit from engagement in services at the current level of care. Treatment at another level of care (more or less intensive) in the same type of service, or discharge from treatment, is therefore indicated; or  The patient has demonstrated a lack of capacity due to diagnostic or co-occurring conditions that limit his or her ability to resolve his or her problem(s). Treatment at a qualitatively different level of care or type of service, or discharge from treatment, is therefore indicated; or  The patient has experienced an intensification of his or her problem(s), or has developed a new problem(s), and can be treated effectively only at a more intensive level of care

Revised: November 15, 2018 Effective January 1, 2019 Page 97 of 126 Medication Assisted Treatment SERVICE DESCRIPTION CRITERIA FOR AUTHORIZATION CONCURRENT REVIEW TRANSITION/ DISCHARGE CRITERIA CRITERIA Medication Assisted Generic Name: Generic Name: It is appropriate to transfer or Treatment (MAT) Buprenorphine/ Naloxone Buprenorphine/ Naloxone discharge the patient from MAT encompasses a variety of Sublingual Film Sublingual Film with Buprenorphine/ Naloxone Brand Name: Suboxone Film Brand Name: Suboxone Film pharmacological Interventions Sublingual Film if he or she meets Tab, Zubsolv Tab, Zubsolv used in the treatment of 1. Has the member one of the following criteria: Opioid Use Disorders or Initial Criteria: maintained abstinence from Alcohol Use Disorders. MAT 1. Does the member have a all substances with the use of  The patient has achieved the can be provided in a variety of DSM-5 diagnosis of Opioid Use Buprenorphine/ Naloxone SL goals articulated in his or her settings, including Opioid Disorder? Film based on negative blood individualized treatment plan Treatment Programs (OTP) or urine toxicology screens, OR and MAT with one of these If yes, continue to #2. If no, do maintained ongoing and Office Based Opioid medication is no longer not approve. participation in a Treatment (OBOT). These comprehensive substance use needed regional guidelines apply to 2. For Opioid Use Disorders, disorder program that includes  The patient is able to Health Share of Oregon has the member failed an psychosocial support? transition to a medication, members receiving services in adequate trial of such as methadone or specialty behavioral health Buprenorphine or If yes, approve for 6 months. If buprenorphine, that does to Buprenorphine/ Naloxone no, continue to #2 settings. require prior authorization Tablets including attempts at a

mitigating strategy (crushing 2. Is there evidence of  The patient has transitioned In the specialty behavioral tablets, taking with food, significantly reduced to MAT with their primary health system, Medication taking small amounts at a utilization of acute care care provider and that Assisted Treatment is provided time) AND there has been services (ED visits, inpatient, provider will work with the concurrently with non- consideration of Naltrexone and/or detox services) and/or patient’s physical health plan tablets and/or Methadone? improved clinical outcomes? pharmacological treatment for prior authorization, if

modalities in all levels of care. needed If yes, continue to #4. If no, go If yes approve for 6 months. If to #3. no, do not approve.

Revised: November 15, 2018 Effective January 1, 2019 Page 98 of 126 Pharmacological agents  The patient no longer meets include opioid agonist 3. Has the provider established concurrent review criteria medications such as a case for clear cost-avoidance with Buprenorphine/ methadone and Naloxone SL Film for the

buprenorphine, and opioid member from their Opioid Use antagonist medications such Disorder AND a trial of or as naltrexone. These Buprenorphine/ Naltrexone medications should be used Tablets or Buprenorphine has for recovery from substance been determined not use disorders, not for the appropriate?

treatment of pain. If yes, continue to #4. If no, do not approve. Please note that prior authorization within the OR specialty behavioral health system is not required for Has the provider established a methadone, buprenorphine, rationale for why alternate medications are medically buprenorphine/ naloxone, or. contraindicated and provided Naltrexone Extended Release information on medications Injection (Vivitrol). Prior tried, adverse outcomes for authorization is required for each, and the dose and Buprenorphine/ Naloxone duration for each medication? Sublingual Film. If yes, continue to #4. If no, do

not approve.

4. Is there documentation that the member is engaged in a substance use disorder

Revised: November 15, 2018 Effective January 1, 2019 Page 99 of 126 treatment program with psychosocial support?

If yes, continue to #5. If no, do not approve.

5. Is there documentation that the member is not concurrently prescribed or taking Buprenorphine/ Naloxone, Buprenorphine, or other opiates from another provider?

If yes, approve for 6 months. If no, do not approve.

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Substance Use Disorder Residential ASAM Levels 3.1, 3.3, and 3.5 SERVICE DESCRIPTION CRITERIA FOR AUTHORIZATION CONCURRENT REVIEW TRANSITION/ DISCHARGE CRITERIA CRITERIA “Residential Alcohol and Other To be appropriate for For continued stay, the Any of the following criteria are Drug Treatment Program" or residential treatment, the individual must continue to sufficient for discharge from this Residential Substance Use individual must meet the meet all the basic elements of level of care: Disorder Treatment means a following conditions medical necessity as defined 1. The individual’s documented publicly or privately operated  Meet DSM-5 criteria for a above. treatment plan goals and program as defined in ORS Substance Use Disorder objectives have been An individualized discharge 430.010 that provides o Moderate or Severe substantially met. plan must have been assessment, treatment, Severity diagnosis 2. The individual is not making developed/updated which rehabilitation, and twenty- o Mild severity only if progress toward treatment includes specific realistic, four hour observation and pregnant woman or high goals despite persistent objective and measurable monitoring for individuals with risk of efforts to engage him/her, discharge criteria and plans for alcohol and other drug medical/behavioral and there is no reasonable appropriate follow-up care. A dependence, consistent with complications expectation of progress at timeline for expected Level 3 of the ASAM Criteria  Meet ASAM Level III criteria this level of care, nor is implementation and 3PrdP Edition. and it is the least restrictive treatment at this level of care completion must be in place appropriate level of care. required to maintain the but discharge criteria have not Residential treatment is a 24  Withdrawal Symptoms, if current level of functioning. yet been met. hour a day/7 day a week present, are not life 3. Support systems, which allow facility-based level of care threatening and can be At least one of the following the individual to be which provides individuals safely monitored at this must be met- maintained in a less with substance use disorders level of care. A. The treatment provided is restrictive treatment therapeutic intervention and  No medical complications leading to measurable environment, have been specialized programming in a that would preclude clinical improvements in

Revised: November 15, 2018 Effective January 1, 2019 Page 101 of 126 controlled environment with a participation in this level of acute symptoms and a thoroughly explored and/or high degree of supervision and care progression towards secured. structure with the purpose of  Cognitively able to discharge from the present 4. The individual can be safely level of care, but the stabilization. Individuals participate in and benefit treated at an alternative level individual is not sufficiently meeting these criteria have from treatment. stabilized so that he/she of care. multiple coexisting can be safely and 5. An individualized discharge complications of their At least one of the following effectively treated at a less plan is documented with substance use disorder. This must be met- restrictive level of care. appropriate, realistic, and may include mental health, B. There is evidence of timely follow-up care in medical, legal or other issues A. The individual suffers from ongoing reassessment and place. that preclude successful co-occurring psychiatric modification to the ISSP, if 6. The individual poses a safety the Individual Services and treatment outside of a 24 hour symptoms that interfere risk to other participants, Support Plan (ISSP) a day therapeutic setting. with his/her ability to implemented is not leading dependents, or staff (for Services and activities are to successfully participate in a to measurable clinical example, physical/verbal be provided in a culturally less restrictive level of improvements in acute violence, smoking in building, appropriate manner. care, but are sufficiently symptoms and a or the use or presence of controlled to allow progression towards alcohol or drugs on discharge from the present Residential treatment participation in residential premises). level of care. addresses stabilization of the treatment. 7. The individual’s mental C. The individual has identified problems through a health or medical symptoms developed new symptoms wide range of diagnostic and B. The individual’s living and/or behaviors that increase to the point that treatment services by reliance environment is such that require this intensity of continued treatment is not on the treatment community his/her ability to service for safe and beneficial at this level of care. setting. Services may address successfully achieve effective treatment. The individual has been (but are not limited to) the abstinence is jeopardized. 2.All of the following must be referred to the appropriate following issues: Examples would be: the met: level. family is opposed to the D. The individual and family are involved to the best of Addiction/relapse treatment efforts, the their ability in the Craving management family is actively involved treatment and discharge

Revised: November 15, 2018 Effective January 1, 2019 Page 102 of 126 Motivation in their own substance planning process, unless Trauma abuse, or the living there is a documented Employment situation is severely clinical contraindication. Education dysfunctional (including E. Continued stay is not Life skills homelessness). primarily for the purpose Recovery support of providing a safe and Housing C. The individual’s social, structured environment Criminality family, and occupational (unless discharge presents Parenting functioning is severely a safety risk to a minor Case Management/Mentoring impaired secondary to child.) Culture/Spirituality substance use disorders F. Continued stay is not Mental Health- such that most of their primarily due to a lack of screening/evaluation daily activities revolve external support unless Medication monitoring and around obtaining, using discharge presents a safety asst with self admin and recuperating from risk to a minor child. Family and/or significant other substance abuse. involvement unless otherwise For authorization of indicated D. The individual is at risk of continued stay, the following exacerbating a serious documentation will be Residential Treatment for medical or psychiatric required: parents with children may condition with continued also include: use and can’t be safely  Re-auth form treated at a lower level of  Copy of current ISSP Childcare care. Child services (e.g. mental  Individual progress notes from the previous 10 days health) E. Either: of service Parenting skills  The individual is likely to Parent/Child interaction experience a deterioration of his/her condition to the

Revised: November 15, 2018 Effective January 1, 2019 Page 103 of 126 Residential Services for youth point that a more restrictive may also include: treatment setting may be required if the individual is Education not treated at this level of Recreation care at this time. Family and/or significant  The individual involvement including DHS, demonstrates repeated Juvenile Justice and natural inability to control his/her supports. impulses to use elicit substances and is in Residential treatment must imminent danger of relapse include an Initial Assessment with resultant risk of harm and Individual Service and to self Support Plan within 24 hours (medically/behaviorally), or of admission. Residential others. This is of such treatment is not based on severity that it requires 24- preset number of days, and hour monitoring/ length of stay will vary based support/intervention. For on the individual’s needs. The individuals with a history of use of evidence based repeated relapses involving practices is expected, to the multiple treatment extent that they are episodes, there must be appropriate for the individual. evidence of the rehabilitative potential for the proposed admission, with clear interventions to address non- adherence/poor response to past treatment episodes

Revised: November 15, 2018 Effective January 1, 2019 Page 104 of 126 and reduction of future of relapse risk.

Initial Authorization Review Process

Initial authorization will be for:  Adult & Youth - 30 days  Parent with child*- 60 day * If parent-child reunification is expected within 60 days, the authorization will be considered a “parent with child” authorization

The program must notify the appropriate BHPP of intake within 2 business days. Notification must be accompanied by the following clinical information:  Initial assessment, including diagnosis  Justification of level of care, including o Presenting problem(s)

Revised: November 15, 2018 Effective January 1, 2019 Page 105 of 126 o History of previous treatment (successful or not) o Drug of choice, longest period of abstinence, most recent use o Referral source and contact information o Pregnancy status (if appropriate) o If parent-child reunification is expected within 60 days, the authorization will be considered a “parent with child” authorization Any of the following criteria is sufficient for exclusion from this level of care. If the individual or dependent child:  Exhibits severe suicidal, homicidal, acute mood disorder, and/or acute thought disorder symptoms, which requires a more intensive level of care.  Can be safely maintained and effectively treated at a less intensive level of care.  Has mental health or medical

Revised: November 15, 2018 Effective January 1, 2019 Page 106 of 126 conditions/impairments that would prevent beneficial utilization of services, or is not medically or psychiatrically stable.  Poses a documented/shown safety risk to the facility, other individuals, themselves or staff.

Revised: November 15, 2018 Effective January 1, 2019 Page 107 of 126 Dual Diagnosis Residential Treatment - ASAM Level 3.5 Youth SERVICE DESCRIPTION CRITERIA FOR AUTHORIZATION CONCURRENT REVIEW TRANSITION/ DISCHARGE CRITERIA CRITERIA Support System Must meet the following: Continues to meet admission At least ONE of the following Requirements:  Covered mental health criteria AND at least one of must be met: Programs offer psychiatric diagnosis on the prioritized the following: services, medication list AND  Documented treatment evaluation and laboratory  Recent psychiatric acute or  Capable of additional goals and objectives have services. Such services are subacute placement within symptom or functional been substantially met available by telephone within the last 6 months OR improvement at this level of  Continuing stabilization can 8 hours and on-site or closely  Extended or repeated crisis care occur with discharge from coordinated off-site within 24 episode(s) requiring  Significant cultural and treatment with medication hours, as appropriate to the increased services AND language barriers impacting management by PCP and/or severity and urgency of the  DSM-5 criteria ability to fully integrate appropriate community patient’s mental condition. o Moderate or Severe symptom management supports Severity diagnosis skills and there is no more  Individual has achieved Staffing Requirements: o Mild severity only if symptom or functional Programs are staffed by clinically appropriate pregnant or high risk of improvement in resolving appropriately credentialed service medical/behavioral issues resulting in mental health professionals,  Active Care Coordination is complication admission to this level of including addiction occurring with mental care psychiatrists who are able to health, A&D and primary AND at least two of the  assess and treat co-occurring care outpatient providers Meets criteria for a following must be met: mental disorders and who different level of care due have specialized training in  Significant risk of harm to to change in symptoms or behavior management self or others function at this level of care techniques.  Moderate to severe or maximum therapeutic impairment of parent/child benefit has been met Some (if not all) of the relationship to meet the addiction treatment developmental and safety needs

Revised: November 15, 2018 Effective January 1, 2019 Page 108 of 126 professionals should have  Moderate to severe sufficient cross-training to functional or developmental understand the signs and impairment in at least one symptoms of co-occurring area, mental disorders, and to  Risk of out of home understand and be able to placement or has had explain to the patient the multiple transition in purposes of psychotropic placement in the last 6 medications and their months due to symptoms of interactions with substance mental illness use.  Risk of school or daycare placement loss due to The intensity of nursing care mental illness or and observation is sufficient to development needs. meet the patient’s needs.  Multiple system involvement requiring Therapy Requirements: coordination and case Programs offer planned management clinical activities designed to  Moderate to severe stabilize the patient’s mental behavioral issues that cause health problems and chronic family disruption psychiatric symptoms, and to  Transition from a higher maintain such level of service intensity stabilization. The goals of (step-down) to maintain therapy apply to both the treatment gains substance use disorder and  Child and/or family’s level of any co-occurring mental English language skill and/or disorder. Specific attention is acculturation is not given to medication education sufficient to achieve and management and to symptom or functional motivational and engagement improvement without case strategies, which are used in management

Revised: November 15, 2018 Effective January 1, 2019 Page 109 of 126 preference to non-evidence- based practices.

Treatment Plan Requirements: Programs provide a review of the patient’s recent psychiatric history and mental status examination. (If necessary, this review is conducted by a psychiatrist.) A comprehensive psychiatric history and examination and psychodiagnostic assessment are performed within a reasonable time, as determined by the patient’s needs.

Programs also provide active assessments of the patient’s mental status, at a frequency determined by the urgency of the patient’s psychiatric symptoms, and follow through with mental health treatment and psychotropic medications as indicated.

Initial authorization: 30 days. All members are initially admitted to A&D Residential and the provider obtains the

Revised: November 15, 2018 Effective January 1, 2019 Page 110 of 126 A&D residential authorization. Within two weeks, members are assessed for meeting criteria for the dual diagnosis program. Provider to submit Mental Health assessment and are provided with a Dual Diagnosis program authorization.

Concurrent authorization: 30 days. Submit updated Mental Health ISSP and treatment plans and progress toward stated goals in the ISSP.

Revised: November 15, 2018 Effective January 1, 2019 Page 111 of 126 Dual Diagnosis Residential Treatment - ASAM Level 3.5 Adult SERVICE DESCRIPTION CRITERIA FOR AUTHORIZATION CONCURRENT REVIEW TRANSITION/ DISCHARGE CRITERIA CRITERIA Support System Must meet the following: Continues to meet admission At least ONE of the following Requirements:  Covered mental health criteria AND at least one of must be met: Programs offer psychiatric diagnosis on the prioritized the following:  Documented treatment services, medication list AND  Capable of additional goals and objectives have evaluation and laboratory  At least one psychiatric symptom or functional been substantially met services. Such services are hospitalization within the improvement at this level of  Continuing stabilization can available by telephone within last 6 months OR care occur with discharge from 8 hours and on-site or closely  Extended or repeated crisis  Significant cultural and treatment with medication coordinated off-site within 24 episode(s) requiring language barriers impacting management by PCP and/or hours, as appropriate to the increased services AND ability to fully integrate appropriate community severity and urgency of the  DSM-5 criteria symptom management supports patient’s mental condition. o Moderate or Severe skills and there is no more  Individual has achieved Staffing Requirements: Severity diagnosis clinically appropriate symptom or functional Programs are staffed by o Mild severity only if service improvement in resolving appropriately credentialed pregnant or high risk of  Active Care Coordination is issues resulting in mental health professionals, medical/behavioral occurring with mental admission to this level of including addiction complication health, substance use care psychiatrists who are able to disorder, and primary care  Meets criteria for a assess and treat co-occurring AND at least two of the outpatient providers different level of care due mental disorders and who following must be met: to change in symptoms or have specialized training in  Risk of harm to self or function at this level of care behavior management others or risk of harm to self or maximum therapeutic techniques. or others that is escalated benefit has been met Some (if not all) of the from baseline addiction treatment  Moderate functional professionals should have impairment in at least two sufficient cross-training to areas (such as housing,

Revised: November 15, 2018 Effective January 1, 2019 Page 112 of 126 understand the signs and financial, social, symptoms of co-occurring occupational, health, mental disorders, and to activities of daily living.) understand and be able to  Multiple system explain to the patient the involvement requiring purposes of psychotropic coordination and case medications and their management interactions with substance  Risk of loss of current living use. situation, in an unsafe living situation, or currently The intensity of nursing care homeless due to symptoms and observation is sufficient to of mental illness meet the patient’s needs.  Significant PTSD or depression symptoms as a Therapy Requirements: result of torture, ongoing Programs offer planned systemic oppression, clinical activities designed to trauma or multiple losses stabilize the patient’s mental  Individual has a health problems and marginalized identity which psychiatric symptoms, and to creates barriers to receiving maintain such appropriate services, and/or stabilization. The goals of individual’s level of English therapy apply to both the language skill and/or substance use disorder and cultural navigation barriers any co-occurring mental is not sufficient to achieve disorder. Specific attention is symptom or functional given to medication education improvement without and management and to additional supports motivational and engagement strategies, which are used in preference to non-evidence- based practices.

Revised: November 15, 2018 Effective January 1, 2019 Page 113 of 126 Treatment Plan Requirements: Programs provide a review of the patient’s recent psychiatric history and mental status examination. (If necessary, this review is conducted by a psychiatrist.) A comprehensive psychiatric history and examination and psycho-diagnostic assessment are performed within a reasonable time, as determined by the patient’s needs.

Programs also provide active assessments of the patient’s mental status, at a frequency determined by the urgency of the patient’s psychiatric symptoms, and follow through with mental health treatment and psychotropic medications as indicated.

Initial authorization: 30 days. All members are initially admitted to Substance Use Disorder Residential and the provider obtains the SUD residential authorization.

Revised: November 15, 2018 Effective January 1, 2019 Page 114 of 126 Within two weeks, members are assessed for meeting criteria for the dual diagnosis program. Provider to submit Mental Health assessment and are provided with a Dual Diagnosis program authorization.

Concurrent authorization: 30 days. Submit updated Mental Health ISSP and treatment plans and progress toward stated goals in the ISSP.

Revised: November 15, 2018 Effective January 1, 2019 Page 115 of 126 Substance Use Disorder High Intensity Medically Monitored Residential - ASAM Level 3.7 Adult SERVICE DESCRIPTION CRITERIA FOR AUTHORIZATION CONCURRENT REVIEW TRANSITION/ DISCHARGE CRITERIA CRITERIA Support System Requirements: Must meet the following Continues to meet At least ONE of the following Physician (or NP, PA or PNP) criteria in two of the admission criteria must be met: assessment within 24 hours of Dimensions with at least one of AND at least one of the criteria in Dimensions 1, 2 admission and as medically the following:  Documented treatment or 3: necessary. goals and objectives have Dimension 1: RN to conduct alcohol or other drug been substantially met  Acute intoxication and/or  Capable of  Continuing stabilization can focused nursing assessment at withdrawal potential: High additional symptom occur with discharge from admission, monitoring progress and risk of withdrawal symptoms or functional treatment with medication medication administration. that can be managed in a improvement at management by PCP and/or Level 3.7 program. this level of care Lab and toxicology service available appropriate community Dimension 2:  Significant cultural on site, along with consultation, and/ supports  Biomedical conditions and and language or referral.  Individual has achieved complications: Moderate to barriers impacting Coordination of services with other symptom or functional severe conditions which ability to fully improvement in resolving levels of care are provided. require 24-hour nursing and integrate symptom issues resulting in Psychiatric services available within 8 medical monitoring or active management skills admission to this level of hours by phone or 24 hours in treatment but not the full and there is no care resources of an acute care more clinically person.  Meets criteria for a hospital. appropriate service Medical Director is an addiction different level of care due Dimension 3:  Active Care specialized physician or psychiatrist to change in symptoms or  Emotional, behavioral, or Coordination is OR a LPN w/CADC to meet function at this level of care cognitive conditions and occurring with or maximum therapeutic biomedical enhanced service complications: Moderate to mental health, benefit has been met description. severe conditions and substance use

Behavioral health specialists dually complications (such as disorder, and primary care trained CADC w/ specific behavioral diagnosable co-morbid

Revised: November 15, 2018 Effective January 1, 2019 Page 116 of 126 health management techniques mental disorders or outpatient training and knowledge of evidence- symptoms). These symptoms providers based practices. may not be severe enough to meet diagnostic criteria but Staffing Requirements: interfere or distract from Interdisciplinary team of recovery efforts (for example, appropriately credentialed anxiety/hypomanic or treatment professionals including depression and/or cognitive addiction credentialed physician. symptoms) and may include Medical professional, nurses, compulsive behaviors, addiction counselors, behavioral suicidal or homicidal ideation health specialists with ASAM specific with a recent history of attempts but no specific plan, knowledge, behavior management or hallucinations and techniques and EBP use providing a delusions without acute risk planned regimen of 24 hour to self or others. professionally directed evaluation,  Psychiatric symptoms are care and treatment services interfering with abstinence, including administration of recovery and stability to such prescribed medications. a degree that the individual needs a structured 24-hour, Therapy Requirements: medically monitored (but not Co-occurring disorder treatment medically managed) facility provides 30 hours of environment to address structured treatment activities per recovery efforts. week including, but not limited to Dimension 4: psychiatric and substance use  Readiness to change: assessments, diagnosis, treatment, Participant unable to and rehabilitation services. acknowledge the relationship At least 10 of the 30 hours is to between the addictive include individual, group, and/or disorder and mental health family counseling. and/or medical issues, or Target population for this LOC are participant is in need of participants with high risk of

Revised: November 15, 2018 Effective January 1, 2019 Page 117 of 126 withdrawal symptoms, moderate co- intensive motivating occurring psychiatric and/or medical strategies, activities, and problems that are of sufficient processes available only in a severity to require a 24-hour 24-hour structured medically treatment LOC. monitored setting (but not All facilities are licensed by OHA. medically managed). Treatment goals are to stabilize a Dimension 5: person who is in imminent danger if  Relapse, continued use, or not in a 24-hour medically monitored continued problem potential: treatment setting Participant is experiencing an Full description is available by escalation of relapse referring to The ASAM Criteria 3rd behaviors and/or acute Edition psychiatric crisis and/or re- Initial authorization: 7 days emergence of acute symptoms and is in need of Concurrent authorization: Up to 7 24-hour monitoring and additional days structured support. Dimension 6:  Recovery environment: Environment or current living arrangement is characterized by a high risk of initiation or repetition of physical, sexual, or emotional abuse or substance use so endemic that the patient is assessed as unable to achieve or maintain recovery at a less intensive level of care.

Revised: November 15, 2018 Effective January 1, 2019 Page 118 of 126 Clinically Managed Withdrawal Management (Detox) – ASAM Level 3.2 Adult and Youth Service Description Clinically Managed Residential Withdrawal Management (Detox): Level 3.2-WM or “social setting detox,” occurs in a freestanding residential setting and is an organized service that includes 24-hour supervision, observation, and support for patients who are intoxicated or experiencing withdrawal. This level is characterized by peer and social support rather than the medical and nursing care. Patients appropriate for this level of care do not require the full resources of a Level 3.7- WM Medically Monitored Inpatient Withdrawal Management program described below.

Since Level 3.2-WM is managed by clinical, not medical or nursing staff, protocols are in place should a patient’s condition deteriorate and appear to need medical or nursing interventions. These protocols are used to determine the nature of the medical or nursing interventions that may be required. Protocols include under what conditions nursing and physician care is warranted and/or when transfers to a medically monitored facility or an acute care hospital is necessary. The protocols are developed and supported by a physician knowledgeable in addiction medicine.

Therapies offered by Level 3.2-WM withdrawal management programs include daily clinical services to assess and address the needs of each patient. Such clinical services may include appropriate medical services, individual and group therapies, and withdrawal support.

Withdrawal Management Services may be offered in any appropriate setting that meets state licensure or certification criteria, including OARs 415-050-000 through 415-050-0095.

Criteria for Authorization Criteria for Clinically Managed Residential Withdrawal Management (Detox): To be appropriate for Clinically Managed Residential Withdrawal Management, the individual must meet the following conditions:

 The patient is experiencing signs and symptoms of withdrawal, or there is evidence (based on history of substance intake; age; gender; previous withdrawal history; present symptoms; physical condition; and/or emotional, behavioral, or cognitive condition) that withdrawal is imminent  The patient is assessed as not being at risk of severe withdrawal syndrome, and moderate withdrawal is safely manageable at this level of service

Revised: November 15, 2018 Effective January 1, 2019 Page 119 of 126 . Alcohol: The patient is intoxicated or withdrawing from alcohol and the CIWA-Ar score is less than 8 at admission, and monitoring is available to assure that it remains less than 8, or the equivalent for a comparable standardized scoring system . Opioids: Withdrawal signs and symptoms are distressing but do not require medication for reasonable withdrawal discomfort and the patient is impulsive and lacks skills needed to prevent immediate continued drug use . Stimulants: The patient has marked lethargy, hypersomnolence, paranoia, or mild psychotic symptoms due to stimulant withdrawal, and these are still present beyond period of outpatient monitoring available in Level 2 WM services

Concurrent Review Criteria It is appropriate to retain the patient at the present level of care if:

 The patient is making progress, but has not yet achieved the goals articulated in the individualized treatment plan. Continued treatment at the present level of care is assessed as necessary to permit the patient to continue to work toward his or her treatment goals; or  The patient is not yet making progress but has the capacity to resolve his or her problems. He or she is actively working on the goals articulated in the individualized treatment plan. Continued treatment at the present level of care is assessed as necessary to permit the patient to continue to work toward his or her treatment goals; and/or  New problems have been identified that are appropriately treated at the present level of care. The new problem or priority requires services, the frequency and intensity of which can only safely be delivered by continued stay in the current level of care. This level is the least intensive at which the patient’s new problems can be addressed effectively

Transition/ Discharge Criteria It is appropriate to transfer or discharge the patient from the present level of care if he or she meets the following criteria:  Withdrawal signs and symptoms are sufficiently resolved that he or she can be safely managed at a less intensive level of care; or  The patient’s signs and symptoms of withdrawal have failed to respond to treatment and have intensified (as confirmed by higher scores on the CIWA-Ar or other comparable standardized scoring system), such that transfer to a Level 3.7- WM or Level 4-WM intensive level of withdrawal management is indicated

Revised: November 15, 2018 Effective January 1, 2019 Page 120 of 126 Medically Monitored Withdrawal Management (Detox) – ASAM Level 3.7 Adult and Youth Service Description Medically Monitored Inpatient Withdrawal Management/ Detox: Level 3.7-WM or a “freestanding withdrawal management/ detox center” is an organized service delivered by medical and nursing professionals, which provides 24-hour evaluation and withdrawal management. Services are provided in a permanent, freestanding facility with inpatient beds that is not a Level 4-WM acute care inpatient hospital setting.

Therapies offered by Level 3.7-WM withdrawal management programs include daily clinical services to assess and address the needs of each patient. Such clinical services may include appropriate medical services, individual and group therapies, and withdrawal support. In addition, hourly nurse monitoring of the patient’s progress and medication administration are available, if needed.

Withdrawal Management Services may be offered in any appropriate setting that meets state licensure or certification criteria, including OARs 415-050-000 through 415-050-0095.

Criteria for Authorization Criteria for Medically Monitored Inpatient Withdrawal Management (Detox): To be appropriate for Medically Monitored Inpatient Withdrawal Management, the individual must meet the following conditions:

 The patient is experiencing signs and symptoms of severe withdrawal, or there is evidence (based on history of substance intake; age; gender; previous withdrawal history; present symptoms; physical condition; and/or emotional, behavior, or cognitive condition) that a severe withdrawal syndrome is imminent.  The severe withdrawal syndrome is assessed as manageable at this level of service. o Alcohol: The patient is withdrawing from alcohol, the CIWA-Ar score is 19 or greater (or the equivalent for a standardized scoring system) by the end of the period of outpatient monitoring available in Level 2-WM. o Alcohol and Sedative/Hypnotics: The patient has marked lethargy or hypersomnolence due to intoxication with alcohol or other drugs, and a history of severe withdrawal syndrome, or the patient’s altered level of consciousness has not stabilized at the end of the period of outpatient monitoring available at Level 2-WM. o Sedative/Hypnotics: The patient has ingested sedative/hypnotics at more than therapeutic levels daily for more than 4 weeks and is not responsive to appropriate recent efforts to maintain the dose at therapeutic levels.

Revised: November 15, 2018 Effective January 1, 2019 Page 121 of 126  The patient has ingested sedative/hypnotics at more than therapeutic levels daily for more than 4 weeks, in combination with daily alcohol use or regular use of another mind-altering drug known to pose a severe risk of withdrawal. Signs and symptoms of withdrawal are of moderate severity, and the patient cannot be stabilized by the end of the period of outpatient monitoring available at Level 2 WM o Alcohol and Sedative/Hypnotics: The patient has marked lethargy or hypersomnolence due to intoxication with alcohol or other drugs, and a history of severe withdrawal syndrome, or the patient’s altered level of consciousness has not stabilized at the end of the period of outpatient monitoring available at Level 2-WM o Opioids: For withdrawal management not using opioid agonist medication: The patient has used Opioids daily for more than 2 weeks and has a history of inability to complete withdrawal as an outpatient or without medication in a Level 3.2-WM service. Antagonist medication is to be used in withdrawal in a brief but intensive withdrawal management (as in multiday pharmacological induction onto naltrexone) o Stimulants: The patient has marked lethargy, hypersomnolence, agitation, paranoia, depression, or mild psychotic symptoms due to stimulant withdrawal, and has poor impulse control and/or coping skills to prevent immediate continued drug use

Concurrent Review Criteria It is appropriate to retain the patient at the present level of care if:

 The patient is making progress, but has not yet achieved the goals articulated in the individualized treatment plan. Continued treatment at the present level of care is assessed as necessary to permit the patient to continue to work toward his or her treatment goals; or  The patient is not yet making progress but has the capacity to resolve his or her problems. He or she is actively working on the goals articulated in the individualized treatment plan. Continued treatment at the present level of care is assessed as necessary to permit the patient to continue to work toward his or her treatment goals; and/or  New problems have been identified that are appropriately treated at the present level of care. The new problem or priority requires services, the frequency and intensity of which can only safely be delivered by continued stay in the current level of care. This level is the least intensive at which the patient’s new problems can be addressed effectively

Revised: November 15, 2018 Effective January 1, 2019 Page 122 of 126 Transition/ Discharge Criteria It is appropriate to transfer or discharge the patient from the present level of care if he or she meets the following criteria:  Withdrawal signs and symptoms are sufficiently resolved that he or she can be safely managed at a less intensive level of care; or  The patient’s signs and symptoms of withdrawal have failed to respond to treatment and have intensified (as confirmed by higher scores on the CIWA-Ar or other comparable standardized scoring system), such that transfer to a Level 4-WM intensive level of withdrawal management in a hospital is indicated

Revised: November 15, 2018 Effective January 1, 2019 Page 123 of 126 Transcranial Magnetic Stimulation Adult SERVICE DESCRIPTION CRITERIA FOR CONCURRENT REVIEW TRANSITION/ DISCHARGE AUTHORIZATION CRITERIA CRITERIA Transcranial Magnetic Stimulation To be considered for a TMS is generally Discharge criteria: Any of the (TMS) is an exceptional needs TMS assessment, the authorized 5 treatments following are sufficient for treatment intervention considered individual must meet All per week for 6 weeks. discharge from this level of only after various trials of different the following criteria: care: therapies and medications, of various Up to 6 taper treatments  Individual has achieved classes, have been exhausted.  Must be 18 years or over three weeks may be adequate stabilization of older authorized. the depressive symptoms. TMS is generally used as a secondary  Major Depressive  Individual no longer meets treatment when the individual has Disorder (MDD), severe The maximum duration of admission criteria, or meets not responded to medication and/or degree without treatment is 9 weeks criteria for a less or more psychotherapy. psychotic features regardless of missed or intensive services.  Must demonstrate skipped treatments.  Individual is not making The TMS treatment is delivered by a resistance to treatment progress toward treatment device that is FDA-approved or FDA- as evidenced by a lack Additional sessions may goals, as demonstrated by cleared for the treatment of MDD in a of clinically significant be authorized in the the absence of any safe and effective manner. response to 4 trials of following circumstances: documented meaningful psychopharmacological measurement The decision to administer TMS must agents from at least two  Persistence of improvement. be based on an evaluation of the risks different agent classes, symptoms with  Worsening of depressive and benefits involving a combination at or above the improvement but where symptoms such as of factors that include psychiatric minimum effective dose maximum benefit has increased suicidal diagnosis, type and severity of and duration, and trials not been achieved thoughts/behaviors or symptoms, prior treatment history of at least two evidence- OR unusual behaviors. and response, and identification of based augmentation  New symptoms or  Member has completed the possible alternative treatment therapies. problems that meet course of 5 treatments per options.  The member has had a clinical criteria for TMS week for 6 weeks and up to trial of evidence-based have emerged. 6 taper treatments over

Revised: November 15, 2018 Effective January 1, 2019 Page 124 of 126 A request for an assessment must be psychotherapy known three weeks (maximum made in writing by the prescriber to be effective duration of treatment is 9 (either a licensed psychiatrist or psych treatment of MDD of an weeks regardless of nurse practitioner) to the assigned adequate frequency and missed/skipped Behavioral Health Plan Partner minimum of 12 weeks treatments). (BHPP)). duration without  Provider has failed to significant improvement monitor, document, and or BHPP Medical Directors will in depressive symptoms report member response to determine whether or not criteria are as documented by treatment. met for an assessment to be covered standard rating scales. by a TMS provider.  A history of clinical response to TMS in a The order for treatment must be previous depressive written by a physician who is board episode. certified and who must have  Client must voluntarily experience in administering TMS agree to TMS therapy and must certify that the assessment treatment will be given under direct supervision of this physician.

Any of the following criteria are sufficient for exclusion from this level of care:  The individual has medical conditions or impairments that would prevent beneficial utilization of the services  The individual requires 24-hour medical/nursing monitoring or procedures provided in a hospital setting.  Younger than 18 years of age or older than 70 years of age.

Revised: November 15, 2018 Effective January 1, 2019 Page 125 of 126  Patients with recent history of active substance abuse, obsessive compulsive disorder, or posttraumatic stress disorder.  Patients with a psychotic disorder, including schizoaffective disorder, bipolar disorder, or MDD with psychotic features.  Patients with neurological conditions that include epilepsy, cerebrovascular disease, dementia, Parkinson’s disease, multiple sclerosis, increased intracranial pressure, having a history of repetitive or severe head trauma, or with primary or secondary tumors in the CNS.  The presence of metal or conductive device in the head or body that is contraindicated with TMS.  Patients with MDD who have failed to receive clinical benefit from ECT or VNS.  Presence of severe cardiovascular disease.  Patients who are pregnant or nursing.  TMS is not indicated for maintenance treatment.

Revised: November 15, 2018 Effective January 1, 2019 Page 126 of 126