Behavioral Health Residential Facilities (BHRF)

Behavioral Health Condition - Mental, Behavioral, or Neurodevelopmental Disorder (F01-F99) diagnosis defined by International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM).

Clinical Practices - The provider’s clinical practices, as applicable to services offered and population served, must demonstrate adherence to best practices for treating the following specialized service needs, which include but are not limited to:

• Cognitive/intellectual disability
• Cognitive disability with comorbid Behavioral Health Condition(s)
• Older adults, and co-occurring disorders (substance use and Behavioral Health Condition(s), or
• Comorbid physical and Behavioral Health Condition(s).

Discharge Plan - During the development of the initial Treatment Planning process, a comprehensive discharge plan is created and reviewed and/or updated at each review thereafter. The discharge plan must document the following:

• Clinical status for discharge;
• Member/guardian/designated representative and, CFT/ART/TRBHA as applicable, understands follow-up treatment, crisis and safety plan, and
• Coordination of care and transition planning are in process (e.g. reconciliation of medications, applications for lower level of care submitted, follow-up appointments made).

Informal Support - Non-billable services provided to a member by a family member, friend or volunteer to assist or perform functions such as, but not limited to; housekeeping, personal care, food preparation, shopping, pet care, or non-medical comfort measures.

Medication Assisted Treatment (MAT) - The use of medications in combination with counseling and behavioral therapies for the treatment of substance use disorders.

Service Plan - A complete written description, of all covered health services and other informal supports, which includes individualized goals, family support services, care coordination activities and strategies to assist the member in achieving an improved quality of life. Services deemed medically necessary through the assessment and/or CFT/ART/TRBHA as applicable, which are not offered at the BHRF, must be documented in the Service Plan and documentation must include a description of the need, identified goals and identified provider who will be meeting the

Treatment Plan - Complete written description of all services to be provided by the Behavioral Health Residential Facility. The Treatment Plan connects back to the member’s comprehensive Service Plan for members enrolled with the ADSS.

Treatment Outcomes - Treatment outcomes must align with all of the following:

• The Arizona Vision-12 Principles for Children’s Behavioral Health Service Delivery
• The 9 Guiding Principles for Recovery-Oriented Adult Behavioral Health Services and Systems
• The member’s individualized basic physical, behavioral, and developmentally appropriate needs.

Treatment Goals - Must be:

• Specific to the member’s behavioral health condition(s)
• Measurable and achievable
• Unable to be met in a less restrictive environment
• Based on the member’s unique needs and tailored to the member and the family’s/guardian’s/designated representative’s choices where possible
• Supportive of the member’s improved or sustained functioning and integration into the community.

Applicable To: Medicaid – Care1st Health Plan Arizona

Arizona Care 1st

Authorization requests for Behavioral Health Residential Facility services are to be treated as expedited requests with a determination decision communicated to the provider within 72-hours of receipt of the request.

Exclusions

The following are exclusionary criteria for admission to a Behavioral Health Residential Facility (BHRF):

• An admission that is not medically necessary; OR
• An admission as an alternative to detention or incarceration; OR
• An admission as an alternative to safe housing, shelter, supervision or permanency placement; OR
• An admission when less restrictive alternatives are available and meet the individual’s needs, including situations when the individual or guardian/designated representative is unwilling to participate in the less restrictive alternative; OR
• An admission where the individual is exhibiting conduct disordered behavior with no presence of risk or functional impairment; OR
• An admission when the individual is exhibiting runaway behaviors unrelated to a behavioral health condition.

In addition, the following are not covered services in a BHRF:

• Room and Board

Coverage

Admission Criteria:

Initial care in a behavioral health residential facility is considered medically necessary when the Behavioral Health Condition causes significant functional and/or psychosocial impairment as evidenced by the following:

• At least ONE area of significant risk of harm within the past 3 months as a result of:
  • Suicidal/aggressive/self-harm/homicidal thoughts or behaviors without current plan or intent; OR
  • Impulsivity with poor judgment/insight; OR
  • Maladaptive physical or sexual behavior; OR
  • Individual’s inability to remain safe within his or her environment, despite environmental supports (i.e. Natural Supports); OR
  • Medication side effects due to toxicity or contraindications

AND

• At least ONE area of serious functional impairment as evidenced by:
  • Inability to complete developmentally appropriate self-care or self-regulation due to Individual’s Behavioral Health Condition(s); OR
  • Neglect or disruption of ability to attend to majority of basic needs, such as personal safety, hygiene, nutrition or medical care; OR
  • Frequent inpatient psychiatric admissions or legal involvement due to lack of insight or judgment associated with psychotic or affective/mood symptoms or major psychiatric disorders; OR
  • Frequent withdrawal management services, which can include but are not limited to, detox facilities, MAT and ambulatory detox OR
  • Inability to independently self-administer medically necessary psychotropic medications despite interventions such as education, regimen simplification, daily outpatient dispensing, and long-acting injectable medications; OR
  • Impairments persisting in the absence of situational stressors that delay recovery from the presenting problem

AND

• The individual is in need of 24-hour behavioral health care and supervision to develop adequate and effective coping skills that will allow the Individual to live safely in the community; AND
• Anticipated stabilization cannot be achieved in a less restrictive setting; AND
• There is evidence that appropriate treatment in a less restrictive environment has not been successful or is not available, therefore warranting a higher level of care; AND
• The individual agrees to, and participates in, treatment. In the case of minors, family/guardian/designated representative also agrees to and participates as part of the treatment team.

Continued Stay Criteria:

The following criteria must be considered when determining continued stay coverage:

• The member continues to demonstrate significant risk of harm and/or functional impairment as a result of a Behavioral Health Condition (see Admission Criteria); AND
• Providers and supports are not available to meet current behavioral and physical health needs at a less restrictive lower level of care, AND

Additionally, the provider shall be able to provide evidence of the following activities:

• Member assessment before treatment is initiated and within 48 hours of admission; AND
• Treatment planning that is based on the intake assessment, the Outpatient Service Plan, and also includes input from the CFT/ART; AND
• Monthly treatment plan reviews and, as applicable, CFT/ART. Treatment plan adjustments to support the need for continued stay which shall include;
  • Assessment of progress toward treatment plan goals; AND
  • Assessment of continued display of risk and functional impairment; AND
  • Assessment of discharge readiness.

Discharge Readiness:

Discharge readiness must be assessed by the BHRF staff and as applicable by the CFT/ART during each Treatment Plan review and update. The following criteria must be considered when determining discharge readiness:

• Symptoms or behavior are reduced as evidenced by completion of Treatment Plan goals.
• Functional capacity is improved; essential functions such as eating or hydrating necessary to sustain life has significantly improved or is able to be cared for in a less restrictive level of care.
• Member can participate in needed monitoring or a caregiver is available to provide monitoring in a less restrictive level of care.
• Providers and supports are available to meet current behavioral and physical health needs at a less restrictive level of care.

Covered CPT Codes: NA

Covered HCPCS Codes: H0018 Behavioral health; short-term residential (nonhospital residential treatment program), without room and board, per diem

Covered ICD-10 Codes: All applicable codes.

Coding information is provided for informational purposes only. The inclusion or omission of a CPT, HCPCS, or ICD-10 code does not imply member coverage or provider reimbursement. Consult the member's benefits that are in place at time of service to determine coverage (or non-coverage) as well as applicable federal/state laws.

References:

Arizona Health Care Cost Containment System Medical Policy Manual (AMPM) Chapter 320-V-Behavioral Health Residential Facilities.

Medical Policy Committee History and Revisions

Adult Behavioral Health Therapeutic Homes (ABHTH)
Original Effective Date: 12/2020
Revised Date(s): 12/2021