2/22/2025
Provider Manual
- Mental Health & Substance Use Disorder/Detoxification
- Residential Treatment for Mental Health and Substance Use Disorders and Residential Facilities - BI449 and BI060
- Billing for Psychotherapy Services
Note: All inpatient, partial inpatient, and intensive outpatient services, whether for medical, surgical, mental health or substance use disorders, require pre-authorization. Residential services are generally not covered.
Eating Disorders
Inpatient and outpatient eating disorder services provided through a structured eating disorders program are considered mental health services, due to their focus on behavioral modification. Services for eating disorders that are primarily medical in nature will be covered as a medical service if the member is under the care of a non-mental health practitioner in an acute bed for the treatment of a medical complication as outlined below:
For members with anorexia, hospital admission is covered under either of the following conditions:
- Individuals with extremely low body weight (75% or less of expected body weight, or a body mass index of 17.5 kg/m2 or lower) whose condition must be hemodynamically stabilized while beginning re-feeding, or
- Individuals with medical problems requiring intensive monitoring such as those with electrolyte imbalances, cardiac arrhythmias, or profound hypoglycemia
For members with bulimia (F50.2, F50.8-50.9), hospital admission is covered for individuals whose binge-purge cycle has resulted in severe metabolic deficiencies such as severe electrolyte imbalances.
Continued hospital stay will be permitted only for the acute management of the metabolic complications and during re-feeding until weight loss has ceased. Members should be discharged when their medical status is stable, i.e., metabolic and nutritional crisis has been resolved, and treatment in an outpatient setting has been arranged. Continued hospitalization in a mental health facility should only be considered if the member is severely depressed or suicidal and will require mental health review and approval.
Mental Health and Substance Use Disorder—Outpatient
Initial therapy or therapy after mental health admission after initial visit is considered medically necessary if a treatment plan demonstrates the continued care is for treatment of crisis leading to symptoms amenable to therapy per applicable care standards. Following the initial visit, a treatment plan provides information to determine the course and progression of ongoing therapy along with expected outcomes. All treatment plans must be available for review by Care Management if requested. Updated treatment plans must demonstrate the following:
- Documented improvement during previous sessions
- Capacity for continued significant improvement
- Demonstrated member cooperation with treatment
Therapy after member discharge from detoxification is considered medically necessary after initial visit if a treatment plan demonstrates the member has completed the first 7 steps of recovery with a sponsor. The initial treatment plan must be available for review by Care Management if requested. Updated treatment plans must demonstrate the following:
- Documented improvement during previous sessions
- Capacity for continued significant improvement
- There has been full cooperation with treatment
Psychiatric diagnostic evaluations are covered once per provider, every 12 weeks. More frequent evaluations per provider within 12 weeks require pre-authorization.
Residential Facilities
Residence in and care provided by a residential facility is typically not covered. Residential facilities may be legally constituted to provide medical and other services to live-in residents. Programs that do not provide skilled medical services on a daily basis are not covered under any circumstances. Residential facility examples include, but are not limited to:
- Substance abuse after-care facilities
- Spinal cord, brain injury, independent living facilities
- Adolescent psychiatric residential facilities
In certain cases, at the sole discretion of QualChoice, the care that is provided by a provider in a residential facility may be covered even if facility charges are not. Pre-authorization is required. Specific cases may warrant an exception to this policy, based on this care being an alternative to care at an acute or sub-acute inpatient facility. All such cases should be referred to Care Management.