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.