Behavioral Health Residential Facilities (BHRF)

Behavioral Health Condition - Mental, Behavioral, or Neurodevelopmental Disorder (F01-F99) diagnosis defined by International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM).

Clinical Practices - The provider’s clinical practices, as applicable to services offered and population served, must demonstrate adherence to best practices for treating the following specialized service needs, which include but are not limited to:

• Cognitive/intellectual disability
• Cognitive disability with comorbid Behavioral Health Condition(s)
• Older adults, and co-occurring disorders (substance use and Behavioral Health Condition(s), or
• Comorbid physical and Behavioral Health Condition(s).

Discharge Plan - During the development of the initial treatment planning process, a comprehensive and viable discharge plan must be created and submitted to the Plan along with supporting clinical information at the time of the initial request in order to be approved. The discharge plan must contain actionable items that are obtainable within 30 to 90 days from date of admission to a BHRF. The discharge plan will include specific levels of care being considered (i.e. SMI housing, outpatient, etc.) as well as alternative options the clinical team will explore in the event the primary plan is not obtainable.  The discharge plan is reviewed and/or updated at each review thereafter, with an update to be provided at each concurrent clinical review. The discharge plan must document the following:

• Clinical status for discharge;
• Current barriers to discharge;
• How are these barriers being addressed;
• Member/Health Care Decision Maker (HCDM)/Designated Representative (DR) and, CFT/ART/TRBHA as applicable, understands follow-up treatment, crisis and safety plan, and
• Coordination of care and transition planning are in process (e.g. reconciliation of medications, applications for lower level of care submitted, follow-up appointments made, ongoing communication with Behavioral Health Outpatient clinic representatives as well as Member/HCDM/DR related to discharge plan status).

Informal Support - Non-billable services provided to a member by a family member, friend or volunteer to assist or perform functions such as, but not limited to; housekeeping, personal care, food preparation, shopping, pet care, or non-medical comfort measures.

Medication Assisted Treatment (MAT) - The use of medications in combination with counseling and behavioral therapies for the treatment of substance use disorders.

Treatment Plan - A complete written description, of all covered health services and other informal supports, which includes individualized goals, family support services, care coordination activities and strategies to assist the member in achieving an improved quality of life. Services deemed medically necessary through the assessment and/or CFT/ART/TRBHA as applicable, which are not offered at the BHRF, must be documented in the Service Plan and documentation must include a description of the need, identified goals and identified provider who will be meeting the

Treatment Outcomes - Treatment outcomes must align with all of the following:

• The Arizona Vision-12 Principles for Children’s Behavioral Health Service Delivery
• The 9 Guiding Principles for Recovery-Oriented Adult Behavioral Health Services and Systems
• The member’s individualized basic physical, behavioral, and developmentally appropriate needs.

Treatment Goals - Must be:

• Specific to the member’s behavioral health condition(s)
• Measurable and achievable
• Unable to be met in a less restrictive environment
• Based on the member’s unique needs and tailored to the member and the family’s/guardian’s/designated representative’s choices where possible
• Supportive of the member’s improved or sustained functioning and integration into the community.

Applicable To: Medicaid – Care1st Health Plan Arizona

Arizona Care 1st

Authorization requests for Behavioral Health Residential Facility services are to be treated as expedited requests with a determination decision communicated to the provider within 72-hours of receipt of the request.

Exclusions

The following are exclusionary criteria for admission to a Behavioral Health Residential Facility (BHRF):

• An admission that is not medically necessary; OR
• An admission as an alternative to detention or incarceration; OR
• An admission as an alternative to safe housing, shelter, supervision or permanency placement; OR
• A behavioral health intervention when other less restrictive alternatives are available and meet the member’s treatment needs, including situations when the member/HCDM is unwilling to participate in the less restrictive alternative; OR
• An admission where the member is exhibiting conduct disordered behavior with no presence of risk or functional impairment; OR
• An admission when the member is exhibiting runaway behaviors unrelated to a behavioral health condition.

In addition, the following are not covered services in a BHRF:

• Room and Board

Coverage

Admission Criteria:

Initial care in a behavioral health residential facility is considered medically necessary when the Behavioral Health Condition causes significant functional and/or psychosocial impairment as evidenced by the following:

1. At least ONE area of significant risk of harm within the past 3 months as a result of:
   • Suicidal/aggressive/self-harm/homicidal thoughts or behaviors without current plan or intent; OR
   • Impulsivity with poor judgment/insight; OR
   • Maladaptive physical or sexual behavior; OR
   • Individual’s inability to remain safe within his or her environment, despite environmental supports (i.e. Natural Supports); OR
   • Medication side effects due to toxicity or contraindications
     
     AND
     
     
2. At least ONE area of serious functional impairment as evidenced by:
   • Inability to complete developmentally appropriate self-care or self-regulation due to Individual’s Behavioral Health Condition(s); OR
   • Neglect or disruption of ability to attend to majority of basic needs, such as personal safety, hygiene, nutrition or medical care; OR
   • Frequent inpatient psychiatric admissions or legal involvement due to lack of insight or judgment associated with psychotic or affective/mood symptoms or major psychiatric disorders; OR
   • Frequent withdrawal management services, which can include but are not limited to, detox facilities, MAT and ambulatory detox OR
   • Inability to independently self-administer medically necessary psychotropic medications despite interventions such as education, regimen simplification, daily outpatient dispensing, and long-acting injectable medications; OR
   • Impairments persisting in the absence of situational stressors that delay recovery from the presenting problem
     
     AND
3. A behavioral health need for 24-hour supervision to develop adequate and effective coping skills that will allow the member to live safely in the community; AND
4. Anticipated stabilization cannot be achieved in a less restrictive setting; AND
5. There is evidence that appropriate treatment in a less restrictive environment (i.e. Intensive Outpatient Treatment) has not been successful or is not available, therefore warranting a higher level of care; AND
6. The member or guardian agrees to participate in treatment. In the case of those who have a HCDM, including minors, the HCDM also agrees to, and participates as part of, treatment team,
7. Agreement to participate in treatment is not a requirement for individuals who are court ordered to a secured BHRF
8. Member’s outpatient treatment team, will be part of the pre-admission assessment and qualified provider. Exception to this requirement exists when the member is evaluated by the the Crisis provider, Emergecny Department, or Behaioal Health Inpatient Facility, and
9. The BHRF will notify the member’s outpatient team of admission prior to creation of the BHRF treatment plan.

Continued Stay Criteria:

The following criteria must be considered when determining continued stay coverage:

1. The member continues to demonstrate significant risk of harm and/or functional impairment as a result of a Behavioral Health Condition (see Admission Criteria); AND
2. Providers and supports are not available to meet current behavioral and physical health needs at a less restrictive lower level of care, AND

Additionally, Care1st utilized INTERQUAL and ASAM criteria guidelines to determine medical necessity in conjunction with guidance from AHCCCS, AMPM 320 V.

1. Continuned stay will be assessed by the BHRF staff and the CFT/ART during Treatment Plan review and updated.
2. Progress towards the treatment goals and continued display of risk and functional impairment will also be addressed.
3. Treatment interventions, frequency, crisis/safety planning, and targeted discharge will be adjusted accordingly to support the need for continued stay.

Discharge Readiness:

Care1st utilizes INTERQUAL and ASAM criteria guidelines to determine discharge readiness in conjunction with guidance from AHCCCS, AMPM 320 V. Discharge planning begins at the time of admission. Discharge readiness must be assessed by the BHRF staff and as applicable by the CFT/ART during each treatment plan review and update.

The following criteria must be considered when determining discharge readiness:

1. Symptoms or behavior are reduced as evidenced by completion of treatment plan goals.
2. Functional capacity is improved; essential functions such as eating or hydrating necessary to sustain life has significantly improved or is able to be cared for in a less restrictive level of care.
3. Member can participate in needed monitoring or a caregiver is available to provide monitoring in a less restrictive level of care.
4. Providers and supports are available to meet current behavioral and physical health needs at a less restrictive level of care.

Notification Timeframes:

Care1st follows contractual, federal, and state standards for the denial and notice of action process provided to enrollees, providers, and facilities. Care1st Medical Directors are responsible for decisions made regarding medical necessity denials.

Initial Requests:
BHRF authorization decisions are made no later than 72 hours from the receipt of the request.

Concurrent Clinical Reviews (CCRs):
BHRF providers will submit clinical information 5 days prior to the last covered day (LCD). BHRF providers will coordinate, if applicable, with a member’s Behavioral Health Outpatient clinic to obtain any additional clinical information to support the continued stay and for ongoing discharge planning.

Timely submission of documentation is essential in order to avoid disruption in service delivery. Care1st will make every effort to support and assist providers in submitting required clinical. A failure to submit documentation timely may resul in a corrective action plan, financial sanctions, and/or a termination of the BHRF contract with the Plan.

Covered CPT Codes: NA

Covered HCPCS Codes: H0018 Behavioral health; short-term residential (nonhospital residential treatment program), without room and board, per diem

Covered ICD-10 Codes: All applicable codes.

Coding information is provided for informational purposes only. The inclusion or omission of a CPT, HCPCS, or ICD-10 code does not imply member coverage or provider reimbursement. Consult the member's benefits that are in place at time of service to determine coverage (or non-coverage) as well as applicable federal/state laws.

References:

1. Arizona Health Care Cost Containment System Medical Policy Manual (AMPM) Chapter 320-V-Behavioral Health Residential Facilities.
2. Arizona Health Care Cost Containment System Operations Manual (ACOM): 414 Requirements for Service Authorization Decisions and Notices of Adverse Benefit Determination.