PMA 10.1.6 Page 1 of 2

Cenpatico Integrated Care (C-IC) uses medical necessity criteria from the American Society of Addiction Medicine (ASAM) for authorization of substance-related treatment. C-IC uses McKesson’s InterQual medical necessity criteria for residential behavioral health inpatient facility authorizations. The InterQual criteria are summarized below.

FOR PRIOR AUTHORIZATION

For admission to this level of care, aperson under the age of eighteen yearsmustmeetboth Clinical Indication criteria 1 and 2 insectionA, both Social Risk criteria 1 and 2 in section B and one Level of Care criterion in section C.

A.CLINICAL INDICATION: Both criterion 1 and 2 must be present within the last week

1.Current psychiatric diagnosis cannot be managed safely at a less intensive level of care

2.Symptoms or behavior: all three criteria must be met:

a.Chronic or persistent danger to self or others as evidenced by one of the following:

  1. Fire setting
  2. Non-suicidal self-injury
  3. Runaway for more than 24 hours and places self in dangerous situations
  4. Daredevil or impulsive behavior
  5. Perpetrator of sexually inappropriate, aggressive or abusive behavior
  6. Unmanageable behaviors: one of the following:
  • Angry outbursts or aggression
  • Delusions, hallucinations, disorganized thoughts, speech or behavior
  • Increased hypomanic symptoms in adolescents
  • Encopresis with feces smearing in persons under thirteen years of age
  • Engaging in delinquent acts in persons under thirteen years of age
  • Persistent violation of court orders in persons under thirteen years of age
  1. Confirmed illegal activity or arrest in adolescents
  2. Persistent violation of court orders in adolescents

b.Danger to self or others present for at least six months

c.Behaviors are expected to persist longer than a year without treatment

B.SOCIAL RISKS: Both criterion 1 and 2 must be met

1.Unsuccessful treatment within the last year as evidenced by one of the following:

a.Intensive community-based treatment

b.HCTC services

c.Behavioral Health Residential Facility

d.At least three psychiatric inpatient admissions

e.At least four psychiatric admissions to any combination of inpatient and intensive outpatient services

2.Support system: one of the following is present within the last month:

a.Unavailable

b.Unable to ensure safety

c.High-risk environment

d.Abusive

e.Intentional sabotage of treatment

f.Unable to manage intensity of person’s symptoms

C.LEVEL OF CARE: One of the following criterion must be met

  1. Discharge or transfer from a psychiatric hospital within the last 24 hours AND one of the following:

a.Persistent, severe, medication-refractory/resistant psychiatric symptoms

b.Hostile or intimidating interactions

  1. Unable or unwilling to follow instructions or negotiate needs
  2. Unable to maintain behavioral control for more than 48 hours AND improvement is expected within the next two weeks

FOR CONTINUED STAY AUTHORIZATION

For authorization of continued service at this level of care, apersonmustmeet at least one Current Symptom criterion insectionA, one Functioning criterion in section B and all six Service criteria in section C.

  1. CURRENT SYMPTOMS OR BEHAVIOR: One of the following criteria within the last week
  1. Disruptive behavior, one of the following within the last week:
  1. Physical altercation or angry outbursts
  2. Destruction of property
  3. Easily frustrated and impulsive
  4. Perpetrator of sexually inappropriate, aggressive or abusive behavior
  5. Runaway from facility or while on home pass
  6. Persistent rule violations
  1. Psychomotor agitation or retardation
  2. Depersonalization or derealization
  3. Hypervigilance or paranoia
  4. Non-suicidal self-injury
  5. Suicidal or homicidal ideation without intent
  6. One of the following psychiatric medication refractory/resistant symptoms persists or is increasing
  1. Anxiety and associated symptoms
  2. Depressed or irritable mood and associated symptoms
  3. Hypomanic symptoms
  4. Obsessions or compulsions
  5. Psychosis and associated symptoms
  1. Symptoms or behavior are improved and discharge is planned within the next week AND one of the following:
  1. Treatment goals are not met
  2. Family or guardian requires further intervention AND return to family is planned
  1. FUNCTIONING: One of the following within the last week:
  1. Unable or unwilling to follow instructions or negotiate needs
  2. Interpersonal conflict as evidenced by one of the following:
  1. Accusatory, threatening or manipulative behavior
  2. Hostile or intimidating behavior
  3. Poor or intrusive boundaries
  4. Unable to establish positive peer or adult relationships
  1. Repeated privilege restriction or loss of privileges
  2. Improved independent functioning with discharge planned within the next week AND therapeutic passes are planned to transition to an alternate level of care
  1. SERVICES: All of the following services within the last week

1.Psychiatric evaluation at least twice a week

2.Clinical assessment at least daily

3.Individual or family psycho-education for adolescents; family psycho-education for children

4.For adolescents: individual, group or family therapy at least five times per week; For children: individual or group therapy at least four times per week and family therapy at least once a week

5.Behavioral contract or symptom management plan

6.School or vocational program

PMA 10.1.6 Page 1 of 2