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KERN COUNTY MENTAL HEALTH SYSTEM OF CARE MANUAL OF POLICIES AND PROCEDURES Issued By: Written By: Revision: Diane Koditek, MFT Director Robin Starzman, RN Authorization System Supervisor New Section No.: 5.1.6 Issue Date: 7/07/00 Effective Date: 4/12/01 Page 1 of 11

MEDICAL NECESSITY FOR OUTPATIENT SPECIALTY MENTAL HEALTH SERVICES: MEDI-CAL, PRIVATE, OTHER, AND REALIGNMENT-FUNDED POLICY: Kern County Department of Mental Health System of Care, as the Mental Health Plan (MHP), will base all screening, assessment tools, and service authorization decisions on the following medical necessity criteria. To determine whether an individual meets medical necessity for initial and ongoing Outpatient Specialty Mental Health Services based upon the specific healthcare coverage. To ensure that each Licensed Professional of the Healing Arts (LPHA) who completes an assessment establishes the need for Outpatient Specialty Mental Health Services through the use of the medical necessity criteria specific to the healthcare coverage. Any decision to initiate Specialty Mental Health Services will be based upon the medical necessity criteria and any other criteria specific to the healthcare coverage. To ensure that each LPHA reevaluates ongoing need for Outpatient Specialty Mental Health Services through the use of the medical necessity criteria. Any decision to continue Specialty Mental Health Services will be based upon the medical necessity criteria and any other criteria specific to the healthcare coverage. Scope: All Children's and Adult Systems of Care county-owned and contracted providers. All Pathfinders for the Specialty Programs as medical necessity pertains to the specific program-funding source. The MHP Authorization Unit for the providers who provide services to individuals who are funded by realignment monies and other Specialty Program providers.

Purpose:

Objective:

Page 2 of 11 Section No.: 5.1.6 BACKGROUND A. The criteria described in this document pertain to Outpatient Specialty Mental Health Services. Each healthcare entity or funding source may have similar medical necessity criteria that have subtle but key differences. It is necessary to check the healthcare coverage or funding source to determine which process to follow to assess for medical necessity and authorize Outpatient Specialty Mental Health Services. Under realignment-funded services, the MHP will first serve persons who are suffering from a mental illness that is serious, persistent, and causing severe functional impairments.* The Decision Trees (attached) incorporate the guidelines to assist MHP clinicians to identify these individuals. *Note: For further information on the population served, see California Welfare and Institutions Code 5600.3 and the California Institute for Mental Health, March 2, 2000, California Public Mental Health Services, Who Is Eligible to Receive Services? document. E. The MHP will review annually the availability of resources to the realignmentfunded program and adjust the medical necessity criteria and the service packages accordingly with the continued goal to meet or exceed the County's obligation to provide emergency services to the qualified individual utilizing Specialty Mental Health Services funded by realignment monies. The development of Service Packages will be used in the evolution of the Managed Care capitation process. For any individual whose services were funded, but for which funding has been lost, the individual must meet medical necessity for realignment-funded services and receive authorization through the Authorization Unit to continue to receive Outpatient Specialty Mental Health Services.

B.

C.

D.

F.

G.

H.

In accordance with W&I Code 14007.5, an individual who is not a citizen of the

Page 3 of 11 Section No.: 5.1.6 United States and who has not been lawfully admitted for permanent residence or permanently residing in the United States under Color of Law and/or has not been deemed a lawful temporary resident or lawful permanent resident, but who is otherwise eligible for MediCal services, may be eligible for care and services that are necessary for the acute symptoms of sufficient severity that the absence of immediate medical attention could reasonably be expected to result in any of the following: placing the individual's health in serious jeopardy; serious impairment to bodily functions; or serious dysfunction to any bodily organ or part. The treatment available to address the emergency may be inpatient or outpatient services. I. For the non-funded individual who has met the criteria for "severe and persistent" serious mental disorder due to being a victim of natural disaster or local emergency, short-term Specialty Mental Health Services may be authorized. Along with the "included" diagnosis and functional impairment caused by that "included" diagnosis, an individual may have an "excluded" coexisting diagnosis.

J.

SEE ATTACHMENTS

Page 4 of 11 Section No.: 5.1.6 ATTACHMENT 1 MEDI-CAL and EPSDT-FUNDED MEDICAL NECESSITY CRITERIA, INCLUDING DIAGNOSES AND SEVERITY CRITERIA Documentation of medical necessity is required for all MediCal and EPSDT Supplemental Specialty Mental Health Service funding reimbursement and is the criterion used to justify service authorization. In accordance with CCR Title 9, Chapter 11, Article 2, Section 1830.205 and WIC Sections 14000-14029, to meet medical necessity, the individual must meet the criteria outlined in A, B, AND C below to be eligible for Specialty Mental Health Services: A. ONE of the following diagnoses in the current Diagnostic and Statistical Manual (DSM): 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. Pervasive Development Disorders, except Autistic Disorders Disruptive Behavior and Attention Deficit Disorders Feeding and Eating Disorders of Infancy or Early Childhood Elimination Disorders Other Disorders of Infancy, Childhood, or Adolescence Schizophrenia and Other Psychotic Disorders Mood Disorders Anxiety Disorders Somatoform Disorders Factitious Disorders Dissociate Disorders Paraphilias Gender Identity Disorders Eating Disorders

Page 5 of 11 Section No.: 5.1.6 15. 16. 17. 18. Impulse Control Disorders Not Elsewhere Classified Adjustment Disorders Personality Disorders Medication-Induced Movement Disorders related to other included diagnosis, AND

B.

An individual must have ONE of the following impairments as a result of the mental disorder(s) listed in Section IA above: 1. 2. A significant impairment in an important area of life functioning; A probability of significant deterioration in an important area of life functioning; or Except as provided in Title IX, Chapter 11, Section 1830.210, the probability that a child will not progress developmentally as individually appropriate. (Note: A child is defined as a person under age 21 years.)

3.

C.

Care delivered must meet 1, 2, AND 3 of the intervention criteria listed below: 1. The focus of the proposed intervention is to address the condition listed in IB above. The expectation is that the proposed intervention will: a. b. Significantly diminish the impairment; or Prevent significant deterioration in an important area of life functioning; or

2.

c.

3.

Except as provided in Title IX, Chapter 11, Section 1830.210, allow the child to progress developmentally as individually appropriate. The condition would not be responsive to physical healthcare-based treatment.

II.

If all of the above criteria are met, the individual will receive Specialty Mental Health Services even when the Individual has a co-existing excluded diagnosis. EXCLUDED DIAGNOSES

D.

Page 6 of 11 Section No.: 5.1.6 A. The following are considered excluded diagnoses*: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. Mental Retardation Learning Disorders Motor Skills Disorder Communication Disorders Autistic Disorder, other Pervasive Developmental Disorders Tic Disorders Delirium, Dementia, and Amnestic and Other Cognitive Disorders Mental Disorders Due to a General Medical Condition Substance-related Disorders Sexual Dysfunctions Sleep Disorders Antisocial Personality Disorder Other Conditions That May Be a Focus of Clinical Attention, except Medication-Induced Movement Disorders, which are included. This list is excerpted from the Rehabilitation Option Manual and the California Institute for Mental Health document and is previously described in the California Code of Regulation CCR.

*

[See attached Decision Tree]

Page 7 of 11 Section No.: 5.1.6 ATTACHMENT 2 MEDICAL NECESSITY CRITERIA FOR MHP REIMBURSEMENT FOR SPECIALTY MENTAL HEALTH SERVICE FOR ELIGIBLE MEDI-CAL BENEFICIARIES UNDER AGE 21 YEARS: EPSDT I. For a MediCal full-scope beneficiary who does NOT meet the medical necessity criteria in IB and IC above, medical necessity criteria IS met when ALL of the following exist: A. The MediCal full-scope beneficiary meets the diagnostic criteria in Attachment 1, section A, above. The MediCal full-scope beneficiary has a condition that would not be responsive to Physical Healthcare-based treatment. The services are: 1. Necessary to correct or ameliorate mental illnesses and conditions discovered by the screening services; Not requested solely for the convenience of the beneficiary, family, physician or another provider of services; Not unsafe or experimental; The most cost-effective; Generally accepted as effective and proven treatments for the conditions for which they are proposed, are within the scope of practice of the provider, and are an appropriate mode of treatment for the health condition of the beneficiary; OR For targeted case management services, the service to which access is to be gained through case management is medically necessary for the beneficiary because: a. The beneficiary has a complicated or complex mental health diagnoses, frequent recent hospitalizations, use of emergency rooms, or other indicators of mental health conditions resulting in significant impairment AND

B.

C.

2.

3. 4. 5.

6.

b.

The beneficiary has a history of one or more environmental risk

Page 8 of 11 Section No.: 5.1.6 factors: primary caregiver has mental retardation or mental illness, physical or sensory disability, substance abuse, under age 18 years, prolonged absence, OR c. Other environmental stressors which may result in neglect, abuse, lack of stable housing, or otherwise compromise the primary caregiver's ability to assist the beneficiary in gaining access to the necessary medical, social, education, and other services.

7.

If the total cost of the provided services are greater than the total cost of an appropriate institutional level of care where equivalent services at the appropriate level are available in a timely manner, the MHP will not approve the Specialty Mental Health Services.

[No Decision Tree at this time]

Page 9 of 11 Section No.: 5.1.6 ATTACHMENT 3 REALIGNMENT-FUNDED MEDICAL NECESSITY CRITERIA: MINORS AND ADULT Under realignment funding, the MHP will first serve individuals who are suffering from a mental illness that is serious, persistent, and causing severe functional impairments. I. Children and Adolescents To meet medical necessity, the individual whose Outpatient Specialty Mental Health Services will be funded by realignment monies must have the following: A. An Included Diagnosis resulting in behavior inappropriate to age and expected developmental norms, AND Due to a mental illness, severe or greater distress in two or more Functional Impairment Areas (school functioning, self care, family relationships, and community functioning) has been in existence for at least six months or is likely to continue for more than one year and the child is at risk of removal or has been removed from home; AND the child displays psychotic features, risk of suicide, or risk of violence, AND 1. 2. Current Global Assessment Functioning Scale rating of 51 or less, OR Historic use of psychiatric hospitalizations. In last year: a. b. Three hospitalizations due to a mental illness, OR Less than three hospitalizations, but total inpatient days 30 days or longer ($15,000), OR State Hospital, Group Home Level 13 or higher, or Therapeutic Behavioral Services (TBS).

B.

c.

C.

OR meets Special Education (AB2726) eligibility requirements.

Note: Primary diagnosis of developmental disability or substance abuse is excluded. Refer to above Attachment 1, section II: Excluded Diagnosis. II. Adults and Older Adults To meet medical necessity, the individual whose Outpatient Specialty Mental Health

Page 10 of 11 Section No.: 5.1.6 Services will be funded by realignment monies must have the following: 1 and 2 and 3 with 4 or 5 or 6: A. B. An Included Diagnosis AND due to a mental illness: Severe or greater distress in three or more Functional Impairment Areas: 1. 2. 3. 4. 5. 6. 7. C. Self care: ability to meet basic daily needs. Physical health: ability to access PHC. Occupational and/or educational. Living arrangement/housing. Economic. Social relationship and primary support. Legal/criminal, AND

Severe or greater distress in above functional impairment areas has been in existence for at least six months or is likely to continue for more than one year substantially enough that it is likely the individual is eligible for entitlements, AND Current Global Assessment Functioning Scale rating of 51 or less OR Historic use of psychiatric hospitalizations: In last year, 1. 2. 3. Three hospitalizations due to a mental illness, OR Less than three hospitalizations, but total of 30 or more inpatient days, OR State hospital, IMD, or MHRC, OR

D. E.

F.

Victim of a natural disaster or local emergency.

Note: Primary diagnosis of developmental disability, substance abuse and acquired traumatic brain injury are excluded. Refer to above Attachment 1, section II: Excluded Diagnosis. [See attached Decision Trees]

Page 11 of 11 Section No.: 5.1.0 ATTACHMENT 4 PRIVATE INSURANCE OR OTHER-FUNDED MEDICAL NECESSITY CRITERIA I. Medical necessity criteria for each private insurance company will differ. During the screening, assessment and referral processes, the provider's access point must refer to the appropriate medical necessity criteria and funding source agreement when determining appropriateness to serve. Services must be pre-authorized by the private insurance company, including Veterans Administration. Medical necessity criteria for MediCare are similar to the MediCal funded criteria. Refer to the MediCare Program Fiscal Intermediary's description of medical necessity.

II.

[No Decision Tree at this time]

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