1.0 BACKGROUND
The Fiscal Year (FY) 1992 Defense Authorization
Conference Report directed the Secretary of Defense to establish
a partial hospitalization benefit. As a result, the partial hospitalization
benefit, previously limited to treatment of alcoholism, was expanded
to cover other mental health disorders. This added level of care
improves the availability of mental health services. The intent
is to provide a needed service at a lower cost than the full hospitalization
rate, and to allow more efficient use of resources for needed mental
health care.
2.0 DESCRIPTION
Psychiatric and SUD partial hospitalization
is a treatment setting capable of providing an interdisciplinary
program of medical therapeutic services, to include management of
withdrawal symptoms as medically indicated. Services may include day,
evening, night, and weekend treatment programs which employ an integrated,
comprehensive and complementary schedule of recognized treatment
approaches. Partial hospitalization is a time-limited, ambulatory,
active treatment program that offers therapeutically intensive,
coordinated, and structured clinical services within a stable therapeutic
environment. Partial hospitalization is an appropriate setting for
crisis stabilization, treatment of partially stabilized mental disorders,
to include substance use disorders, and a transition from an inpatient
program when medically necessary. To be approved, such programs
must enter into a participation agreement, and be accredited and
in substantial compliance with the Joint Commission (TJC), the Commission
on the Accreditation of Rehabilitation Facilities (CARF), the Council
on Accreditation (CoA), or an accrediting organization approved
by the Director, Defense Health Agency (DHA). The regional contractor
may submit, via the TRICARE Regional Office (TRO), additional accrediting
organizations for TRICARE authorization, subject to approval by
the Director, DHA.
3.0
POLICY
3.1 Treatment of Mental Disorders
In order to qualify for mental health or SUD
benefits, the patient must be diagnosed by a licensed, qualified
mental health professional, and be suffering from a mental disorder,
according to the criteria listed in the current edition of the Diagnostic
and Statistical Manual of Mental Disorders (DSM) or a mental
health diagnosis in the International Classification of Diseases,
9th Revision, Clinical Modification (ICD-9-CM) for diagnoses made
before the mandated date, as directed by Health and Human Services
(HHS), or the International Classification of Diseases, 10th Revision,
Clinical Modification (ICD-10-CM) implementation, after which the
ICD-10-CM diagnoses must be used. Benefits are limited for certain
mental disorders, such as specific developmental disorders. No benefits are
payable for “Conditions Not Attributable to a Mental Disorder,”
or ICD-9-CM V codes, or ICD-10-CM Z codes.
Co-occurring mental and SUDs are common and assessment should proceed
as soon as it is possible to distinguish the substance related symptoms
from other independent conditions. In order for treatment of a mental
disorder to be medically or psychologically necessary, the patient
must, as a result of a diagnosed mental disorder, be experiencing
both physical or psychological distress and an impairment in his
or her ability to function in appropriate occupational, educational,
or social roles. It is generally the degree to which the patient’s
ability to function is impaired that determines the level of care
(if any) required to treat the patient’s condition.
3.2 The purpose of partial hospitalization is to
provide an appropriate setting for crisis stabilization, treatment
or partially stabilized mental or SUDs, and as a transition from
an inpatient program when medically or psychologically necessary
to avoid a serious deterioration in functioning within the context
of a time-limited, ambulatory, active treatment program that offers
therapeutically intensive, coordinated, and structured clinical
services within a stable therapeutic environment.
3.3 A Primary Care Manager (PCM)
referral is required for PHP services. Preauthorization
is not required for admission to a PHP.
However, if
the PHP provider is a network provider, a request for preauthorization
from the network provider to the contractor may be accepted in lieu
of PCM referral. Contractors remain responsible for
ensuring covered care is medically or psychologically necessary
and appropriate.
See Sections 3.5 and 3.8 regarding referral and preauthorization
requirements.
3.4 Criteria for determining medical
or psychological necessity of partial hospitalization services. PHP services
will be considered necessary only if all of the following conditions
are present:
3.4.1 The patient is suffering significant impairment
from a mental disorder to include SUD (as defined in
32 CFR 199.2) which interferes with age appropriate
functioning or the patient is in need of rehabilitative services
for the management of withdrawal symptoms from alcohol, sedative-hypnotics, opioids,
or stimulants that require medically-monitored ambulatory detoxification,
with direct access to medical services and clinically intensive
programming of rehabilitative care based on individual treatment
plans;
3.4.2 The patient is unable to maintain himself or
herself in the community, with appropriate support, at a sufficient
level of functioning to permit an adequate course of therapy exclusively
on an outpatient basis (but is able, with appropriate support, to
maintain a basic level of functioning to permit partial hospitalization
services and presents no substantial imminent risk of harm to self
or others);
3.4.3 The patient is in need of crisis stabilization,
treatment of partially stabilized mental health disorder or SUD,
or services as a transition from an inpatient program;
3.4.4 The admission
into the PHP is based on the development of an individualized diagnosis and
treatment plan expected to be effective for that patient and permit
treatment at a less intensive level.
3.5 Authorized
PHPs must have entered into participation agreements (see
Chapter 11, Addendum F) to provide multi-disciplinary
programs in exchange for all-inclusive per diem reimbursement. Professional
services provided by a qualified mental health provider that do
not duplicate treatment provided in a PHP may be billed separately.