12/3/2024

Provider Manual

Mental Health Coverage

Overall health is broader than just physical health and includes mental health treatment, as well. QualChoice complies with and maintains parity between administration of mental health/substance use disorder benefits and medical/surgical benefits as outlined in applicable federal and state law or regulation and any related binding regulatory or sub-regulatory guidance. We cover the treatment and diagnosis of many mental health disorders as outlined in our medical policies.

Medical Coverage Policies

  • Autism Spectrum Disorder Treatment - QCP.PP.044
  • Hypnotherapy Services - QCP.CP.014
  • 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.

Autism Spectrum Disorder Treatment

The diagnosis and treatment of Autism Spectrum Disorder (ASD) is covered. However, many therapies must be pre-authorized, and require periodic re-evaluation (as with any therapy) to review the updated treatment plan, goals and documented benefits of interventions. Pre-authorization for further treatments will be based on the information provided in the periodic re-evaluation.

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.

Hypnotherapy

Hypnotherapy or meditation therapy provided as part of psychotherapy under the direction of a network practitioner is covered when determined to be appropriate for the member’s diagnosis. Pre-authorization is required. Coverage is limited by the mental health benefits in the member’s policy.

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.

Detoxification

Acute drug and alcohol detoxification services (medical management of the withdrawal syndrome) are distinct from drug and alcohol treatment and are eligible for coverage consistent with other medical services. The contracts and provisions of the medical benefit apply.

Determination of medical necessity for either involuntary (emergency admission, self-directed or through third-party intervention) or voluntary (pre-authorized as necessary prior to treatment) admission is based on the need for medical management of the withdrawal syndrome or any concomitant medical condition which might require hospitalization as determined by a Plan physician, and as found to be medically necessary by a QualChoice/QCA Medical Director.

Residential Treatment for Mental Health & Substance Use Disorders

Certain plans provide coverage for residential mental health or substance use disorder treatment facilities; members should refer to their policy documents. Care for mental health or substance use disorders in a residential treatment facility is covered only when part of a treatment plan pre-authorized by QualChoice.

A residential treatment facility for mental health or substance use disorders is a 24-hour facility that is not a hospital. These facilities provide a controlled, structured environment that is designed to improve the effectiveness of therapy. Residential treatment facilities are not for providing housing or custodial care, or simply to change the person’s environment.

Mental Health Residential Treatment Center

Member’s symptoms or condition must meet the diagnostic criteria for a DSM Axis I or ICD Diagnosis that is consistent with symptoms, and the primary focus of treatment is residential treatment center (RTC) psychiatric care. All services must meet the definition of medical necessity in the member’s plan document.

Residential Treatment Detoxification for Substance Use Disorder

Member’s symptoms or condition must meet the diagnostic criteria for a DSM Axis I or ICD Substance Dependence diagnosis for residential treatment detoxification. All services must meet the definition of medical necessity in the member’s plan document.

Residential Treatment Center for Substance Abuse Disorder

Member’s symptoms or condition must meet the diagnostic criteria for a DSM Axis I or ICD Substance Abuse and/or Dependence diagnosis for residential treatment center treatment. All services must meet the definition of medical necessity in the in the member’s plan document.

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.

Billing for Psychotherapy Services

CPT Code 90863, Pharmacologic Management, designates pharmacologic management by providers who do not use Evaluation and Management (E&M) codes, such as psychologists who are permitted, in some other states, to prescribe and manage medications. Arkansas does not permit psychologists to prescribe medications, so this code is not covered. When pharmacological management is provided by a physician, the appropriate E&M code should be used.

When a physician sees a member for management of a mental health issue without providing psychotherapy, the appropriate E&M code (99201 - 99499) should be used for the encounter. When a physician sees a member for management of a mental health issue that involves pharmacological management along with psychotherapy, the appropriate E&M code should be used for that portion of the visit that involves pharmacological management. The appropriate psychotherapy add-on code (90833, 90836 or 90838) is used for the portion of the visit dedicated to psychotherapy.

CPT Code 90785, Interactive Complexity, indicates that a particular psychotherapy session is rendered more complex by communication issues not caused by the member’s disorder, such as interference by a caregiver or need to use toys to overcome communication barriers. This code may only be added to psychotherapy codes 90791 - 90792 or 90832 - 90838. It is not to be added to a session which is billed using only an E&M code. Evaluation and Management codes are not billable by mental health professionals other than physicians.

Definitions for Levels of Care

QualChoice recognizes the following distinct levels of care.

Psychiatric Disorder Levels of Care

  • Acute inpatient: The highest intensity of medical and nursing services provided within a structured environment providing 24-hour skilled nursing and medical care. Full and immediate access to ancillary medical care must be available for those programs not housed within general medical centers.
  • Residential treatment: Care provided at a 24-hour, state-licensed sub-acute level with licensed healthcare professionals.
  • Partial hospital: An intensive non-residential level of service where multidisciplinary medical and nursing services are required. Care is provided in a structured setting, similar in intensity to inpatient, meeting for more than 4 hours and generally less than 8 hours daily.
  • Intensive outpatient: Multidisciplinary, structured services provided at a greater frequency and intensity than routine outpatient treatment. These are generally up to 4 hours per day, up to 5 days per week. Common treatment modalities include individual, family, and group psychotherapy and medication management.
  • Outpatient: The least intensive level of service, provided in an office setting. Individual psychotherapy sessions last for up to 60 minutes per day and group psychotherapy sessions for up to 90 minutes per day.

Substance Use Disorder Levels of Care

  • Inpatient detoxification:Services provided in an inpatient setting with full skilled nursing and medical care, generally on inpatient or sub-acute units. Can also be provided on a medical/surgical unit or other medical hospital unit when needed for safety or in the absence of adequate services elsewhere.
  • Inpatient rehabilitation: Care provided at an inpatient facility or sub-acute level with skilled nursing care after a member has fully or partially recovered from acute detoxification symptoms and no longer requires intensive medical monitoring.
  • Residential treatment: Care provided at a 24-hour, state-licensed sub-acute level with licensed healthcare professionals.
  • Outpatient/ambulatory detoxification: Services delivered within a structured program having medical and nursing supervision where physiological consequences of substance withdrawal are not life threatening. 
  • Partial hospital: An intensive, non-residential level of care where multidisciplinary medical and nursing services are required. Care is provided in a structured setting, similar in intensity to an inpatient setting, meeting for more than four hours and generally, less than 8 hours daily. Such care is appropriate for substance use disorder treatment when provided in conjunction with ambulatory detoxification or when medical co-morbidity or other complications make less intensive levels of care unsafe or inadequate.