Information For Dates of Service Before October 1, 2015

Guidelines for Prior Authorization of Adult Mental Health Day Treatment Services

Use the following information to complete the PA/AMHDTA:

1. The target population for extended day treatment services are persons with long-term and persistent mental illness or those that have an acute exacerbation of a long-term and persistent mental illness (supported by diagnosis and narrative summary).
   
   
2. The following are diagnostic limitations (Diagnostic and Statistical Manual of Mental Disorders, Third Edition) for adult mental health day treatment services:
   1. Allowable diagnoses:
      1. Certain psychoses: 295 (Schizophrenic disorders), 296 (Episodic mood disorders, includes episodic affective disorders), and 298 (Other nonorganic psychoses).
      2. Other Disorders: 301 (Personality disorders) and 311 (Depressive disorder, not elsewhere classified).
   2. Possible diagnoses (with careful scrutiny): 300 (Anxiety, dissociative and somatoform disorders), usually limited to 300.11, 300.3, 300.4, 300.81, and 300.9 (the narrative must document interference in life functioning).
   3. All other mental disorder diagnoses as the only (or primary) diagnosis are deemed inappropriate for adult mental health day treatment (i.e., 290-294, 297, 299, 303-305.9, 310) and cannot be covered.
   
   
3. The request must include a Mental Health Day Treatment Functional Assessment, completed within three months prior to the request’s date. Requests not meeting this criteria should be returned to the provider. (Refer to DHS 107.13[4][b]2.f., Wis. Admin. Code, for more information.)
   
   
4. A member must have at least a 50 percent likelihood to benefit from day treatment in order to qualify for PA, as indicated on the Mental Health Day Treatment Functional Assessment.
   
   
5. The member must be 18 years of age or older to qualify for adult mental health day treatment services under these guidelines.
   
   
6. Those members suffering from acute mental illness or a mild mental disorder (i.e., by diagnosis and history they are not suffering from a chronic malady) are generally eligible for hours of treatment preceding the PA threshold. Additional hours may be approved at the consultant’s discretion.
   
   
7. A member with 317 (Mild intellectual disability) as the only (or primary) diagnosis is not eligible for adult mental health day treatment services.
   
   
8. A member whose IQ is 65 or less is not ordinarily eligible for adult mental health day treatment services. The consultant may approve treatment if there is documentation that the member would be able to benefit from a treatment program meeting all other requirements for adult mental health day treatment.
   
   
9. A member who, according to the documentation submitted, is currently abusing alcohol or other drugs is generally not eligible for adult mental heath day treatment services. Adult mental health day treatment may be approved at the consultant’s discretion if evidence of concurrent substance abuse treatment is presented. However, no intensive outpatient substance abuse and adult mental health day treatment may be approved concurrently.
   
   
10. A member who, by narrative description, is primarily a victim of parental/relationship alcoholism, drug abuse, physical abuse, sexual abuse, or incest, is not generally eligible for generic adult mental health day treatment services. The consultant may approve treatment if there is documentation that the member would be able to benefit from a treatment program meeting all other requirements for day treatment.
    
    
11. A member who, by narrative description, has an identified eating disorder, sexual addiction, or other compulsive/addictive malady is not generally eligible for generic adult mental health day treatment services. The consultant may approve treatment if there is documentation that the member would be able to benefit from a treatment program meeting all other requirements for adult mental health day treatment.
    
    
12. The following categories with hour and time limitations, along with consultant knowledge of the member’s needs, the provider, and the program offered, are to be used in deciding authorization for the target populations (refer to numbers 1 and 2 listed previously):
    1. Rehabilitation. This category is used for all of the target adult mental health day treatment population who may benefit by intensive adult mental health day treatment. Members believed to be in this category would receive, at the consultant’s discretion, the following:
       1. Threshold hours.
       2. One authorization extension for six months (if requested) of up to 25 hours per week.
       3. Two additional authorization extensions of 10 to 25 hours per week for three months, only if all of the following occur:
          • Improvement is shown in the Mental Health Day Treatment Functional Assessment scores (i.e., LOF and COF).
          • A plan is developed to transfer the member to ongoing community support, vocational rehabilitation, therapeutic living arrangement, etc.
          • There is evidence this process will be completed within one year (e.g., indicated by termination date, previous performance, rehabilitation potential, and narrative history).
          • The narrative indicates that, in the judgment of the provider, rehabilitation potential is “good” or better.
    2. Maintenance. This category is for those members who, by diagnosis or history, are suffering from a long-term and persistent mental illness or those who have acute exacerbation of a long-term and persistent mental illness as indicated by diagnosis, signs of illness for two or more years, and past intensive adult mental health day treatment has already been tried for six months or more with no apparent change in functional assessment or narrative history. The major goal of adult mental health day treatment here is to maintain the individual in the community and prevent hospitalization. Members in this category would receive the following at the consultant’s discretion:
       1. Authorization extension for one to six hours per week, for as long as needed (extension length up to 12 months, or the remainder of the calendar year, if requested).
       2. Authorization extension may also be granted for six to 10 hours per week, for three to 12 months (or the balance of the calendar year), depending on the member’s needs, consultant knowledge of the provider, and the provider’s adult mental health day treatment program.
    3. Stabilization. This category is for those members in the target population who decompensate or have acute exacerbation of a chronic condition. The goal in this category is to “increase structure,” stabilize the member, prevent harm to self or others, and prevent hospitalization. Decompensation would be indicated by a recent hospitalization (i.e., within the last 30 days) or other acceptable signs of clear deterioration in LOF and COF. The member in this category would receive the following at the consultant’s discretion:
       1. Initially, an extension of up to 25 hours per week for a single three-month period.
       2. Following this, one extension returning to maintenance level (1-10 hours per week), unless rehabilitation potential is clearly demonstrated.
    
    
13. Other general considerations for determining adult mental health day treatment hours and eligibility are, at the consultant’s discretion, as follows:
    1. The LOF score must be between three and 12 for a member to be eligible for adult mental health day treatment.
    2. The COF score must be between five and 12 for a member to be eligible for adult mental health day treatment.
    3. If the COF is greater than 12, then the risk of hospitalization needs to be at least 75 percent for a member to be eligible for adult mental health day treatment.
    4. If the member is in a therapeutic or supportive working and living arrangement (i.e., CBRF, sheltered workshop, group home, foster home, or intact family), then fewer hours are indicated for adult mental health day treatment.
    5. Discharge from one adult mental health day treatment program to a vocational rehabilitation (sheltered workshop) setting prohibits another intensive mental health day treatment series, unless other criteria are met.
    6. A member who is involved in primary substance abuse treatment is not generally eligible for adult mental health day treatment services. However, if the member has completed primary substance abuse treatment and is in an aftercare service, he or she is eligible for concurrent adult mental health day treatment services at the consultant’s discretion. The hours granted would generally fall into the maintenance category.
    7. The following activities are not reimbursed as adult mental health day treatment hours: meal times, rest periods, transportation, recreation, entertainment, and off-site visits and activities.