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.