If DSS/DJJ/Legal involvement, a tag has been created in AlphaMCS. Met Not N/A Note status of involvement here: Met FOR STATE FUNDED, is the State funded Benefit Plan accurate? Met Not N/A Please add the following verification statement to the Justification Statement: “There is Met evidence to support the Beneficiary meets the eligibility criteria of the Benefit Plan identified: (Benefit Plan)” Psychiatric Rehabilitation Treatment Facility Diversion and Assessment Program Clinical Coverage Policy 8D-1 State Funded MH/SA/DD Service Definitions Service Code 0911 (modifier pending) Specific Criteria Medicaid shall cover admission to Psychiatric Rehabilitation Treatment Facilities when the Beneficiary meets all of the following criteria: The beneficiary demonstrates symptomatology consistent with a DSM-5, or any subsequent editions of this reference material, diagnosis which requires and can Met Not Met reasonably be expected to respond to therapeutic intervention AND As evidenced by: The beneficiary is experiencing emotional or behavioral problems in the home, community or treatment setting and is not sufficiently stable either emotionally or Met Not Met behaviorally, and is in need of a comprehensive evaluation to determine if the client can be treated outside of a highly structured 24-hour therapeutic environment AND As evidenced by: The beneficiary demonstrates a capacity to respond favorably to rehabilitative counseling and training in areas such as problem solving, life skills development, and Met Not Met medication compliance training AND As evidenced by: The beneficiary has a history of multiple hospitalizations or other treatment episodes or recent inpatient stay with a history of poor treatment adherence or outcome or is Met Not Met at risk of hospitalization/incarceration and is in need of a comprehensive evaluation to determine discharge treatment and supervision options OR As evidenced by: A comprehensive evaluation is needed to determine if less restrictive or intensive levels of treatment are appropriate to meet the client’s needs OR Met Not Met As evidenced by: A comprehensive evaluation is needed to determine if the family situation and functioning levels are such that the beneficiary can return to the home environment Met Not Met and receive community-based treatment. As evidenced by:
Met Not Met N/A If DSS/DJJ/Legal involvement, a tag has been created in AlphaMCS. Note status of involvement here: Met Not Met N/A FOR STATE FUNDED, is the State funded Benefit Plan accurate? Please add the following verification statement to the Justification Statement: “There is evidence to support the Beneficiary meets the eligibility criteria of the Benefit Plan identified: (Benefit Plan)” Psychiatric Rehabilitation Treatment Facility Diversion and Assessment Program Clinical Coverage Policy 8D-1 State Funded MH/SA/DD Service Definitions Service Code 0911 (modifier pending) Specific Criteria Medicaid shall cover admission to Psychiatric Rehabilitation Treatment Facilities when the Beneficiary meets all of the following criteria: Met Not Met The beneficiary demonstrates symptomatology consistent with a DSM-5, or any subsequent editions of this reference material, diagnosis which requires and can reasonably be expected to respond to therapeutic intervention AND As evidenced by: Met Not Met The beneficiary is experiencing emotional or behavioral problems in the home, community or treatment setting and is not sufficiently stable either emotionally or behaviorally, and is in need of a comprehensive evaluation to determine if the client can be treated outside of a highly structured 24-hour therapeutic environment AND As evidenced by: Met Not Met The beneficiary demonstrates a capacity to respond favorably to rehabilitative counseling and training in areas such as problem solving, life skills development, and medication compliance training AND As evidenced by: Met Not Met The beneficiary has a history of multiple hospitalizations or other treatment episodes or recent inpatient stay with a history of poor treatment adherence or outcome or is at risk of hospitalization/incarceration and is in need of a comprehensive evaluation to determine discharge treatment and supervision options OR As evidenced by: Met Not Met A comprehensive evaluation is needed to determine if less restrictive or intensive levels of treatment are appropriate to meet the client’s needs OR As evidenced by: Met Not Met A comprehensive evaluation is needed to determine if the family situation and functioning levels are such that the beneficiary can return to the home environment and receive community-based treatment. As evidenced by: