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Medical Necessity Criteria
1. 000 INTRODUCTION   

SECTION

TITLE

DATE REVISED

1.100

Individuals Served by VBH-PA’s Public Sector Programs

 

1.200

Clinical Criteria Manual Development

 

2. 000"" CLINICAL CRITERIA

2.000

Clinical Criteria Concepts

 

2.100

Assessment and Referral
Risk-Rating Scale

 

2.200

Determining Clinical Necessity

 

2.300

Determining Appropriate Level of Care

 

2.400

Evaluating Clinical Necessity for Continued Care

 

2.500

Discharge Criteria

 

3. 000""

SERVICE MANAGEMENT

3.100

Overview

 

3.200

Outcomes

 

3.300

Individualized Service Plans

 

3.400

Coordination of Care

 

3.500

Discharge and Transition Plans

 

4.000""

IN-PLAN ADULT MENTAL HEALTH SERVICES
4.100 Emergency/Crisis Services

4.101

Telephone Crisis Service

 

4.102

Walk-in Crisis Service

 

4.103

Mobile Crisis Service

 

4.200 Inpatient Programs

4.201

Acute Inpatient Mental Health

 

4.202

Subacute Inpatient Mental Health

 

4.300 Outpatient Treatment

4.300

Outpatient Psychotherapy Criteria

 

4.301

Outpatient therapy

 

4.302

Psychological Testing

 

4.303

Family Therapy

 

4.304

Partial Hospitalization

 

4.306

Medication Management

 

4.307

Group Psychotherapy

 

4.308

Diagnostic Evaluation

 

4.309

Intensive Outpatient Programs (IOP) Adults

 

4.400 Case Management

4.401-
4.402

Intensive Case Management for Adults/Resource Coordination for Adults

 

4.500 Clozapine Support Services

4.501

Clozapine (Clozaril Management)

 

4.600

Electroconvulsive Therapy (ECT)

 

4.601

Electroconvulsive Therapy (ECT)

 

Pennsylvania’s Client Placement Criteria for Adults (PCPC)

5.000

Level I (PCPC)

5.100

Pennsylvania’s Client Placement Criteria for Adults (PCPC) Entire Document

 

5.101

Outpatient (1A)

 

5.102

Intensive Outpatient (1B)

 

5.200 Level II (PCPC)

5.201

Partial Hospitalization (2A) (Supplemental Service)

 

5.202

Halfway House (2B)

 

5.300 Level III (PCPC)

5.301

Medically Monitored Inpatient Detoxification (3A)

 

5.302

Medically Monitored Short-Term Residential (3B)

 

5.303

Medically Monitored Long-Term Residential (3C)

 

5.400 Level IV (PCPC)

5.401

Medically Managed Inpatient Detoxification (4A)

 

5.402

Medically Managed Inpatient Residential (4B)

 

5.405

Pennsylvania’s Client Placement Criteria for Adults (PCPC) Appendix A Special Needs

 

5.500 Methadone Maintenance Services

5.501-
5.502

Standard Level, Intense Level

 

5.700

Comprehensive Psychiatric Evaluation

 

6.000""

IN PLAN CHILD/ADOLESCENT MENTAL HEALTH SERVICES
6.100

Emergency / Crisis Services

6.101

Telephone Crisis Service

 

6.102

Walk In Crisis Service

 

6.103

Mobile Crisis Service

 

6.200

Inpatient Programs

6.201

Acute Inpatient Mental Health

 

6.202

Subacute Inpatient Mental Health

 

6.300 Non-Hospital, Out-of-Home Placement

6.301

Residential Treatment (JCAHO and non-JCAHO)

 

6.302

Community Residential Rehabilitation Host Home

 

6.400 Outpatient Treatment

6.400

Outpatient Psychotherapy Criteria

 

6.401

Outpatient Therapy

 

6.402

Partial Hospitalization

 

6.403

Psychological Testing

 

6.404

Group Psychotherapy

 

6.405

Family Therapy

 

6.406

Medication Management

 

6.407

Diagnostic Evaluation

 

6.408

Intensive Outpatient Program (IOP) Child / Adolescent)

 

6.500 Case Management Services

6.502-
6.503

Resource Coordination & Intensive Case Management (Children / Adolescent)

 

6.600 Family Based Mental Health Services

6.601

Family Based Mental Health Services

 

 7. 000 IN PLAN ADOLESCENT DRUG AND ALCOHOL SERVICES

7.001

Adolescent ASAM Criteria 2001 Cliff notes

 

7.002

Adolescent ASAM Criteria 2001 Cliff Notes (III & IV)

 

7.003

Adolescent ASAM Criteria Overview

 

7.100

Level 0.5 (ASAM PPC-2) Early Intervention

 

7.200

Level I (ASAM PPC-2) Outpatient Services

 

7.300

Level II (ASAM PPC-2) Intensive Outpatient/Partial Hospitalization Services (Supplemental Service)

 

7.400

Level III (ASAM PPC-2) Medically-Monitored Intensive Inpatient Services

 

7.500

Level IV Medically-Managed Intensive Inpatient Services

 

7.600

Drug and Alcohol Assessment/Level of Care Determination

 

8.000  BEHAVIORAL HEALTH REHABILITATION (EPSDT) SERVICES

8.000

Children and Adolescents BHRS Services
Appendix T Part B (2)

 

8.400

Summer Therapeutic Activities Program

 

9.000  SUPPLEMENTAL ADULT MENTAL HEALTH SERVICES

 

Residential Programs

 

9.103

Crisis Residential Services

 

9.104

Long Term Structured Residential Treatment Centers

 

9.200 Outpatient Treatment

9.201

 Psychiatric Rehabilitation Program

9-20-07

10.000  SUPPLEMENTAL ADULT DRUG AND ALCOHOL SERVICES

10.101

Drug and Alcohol Intensive Case Management (Formerly, Targeted Case Management) For Adults

 

10.102
Drug and Alcohol Assessment / Level of Care determination  

10.105

Partial Hospitalization (2A) (PCPC)

 

 11.000   SUPPLEMENTAL CHILD/ADOLESCENT MENTAL HEALTH SERVICES
11.600

Crisis Residential Service

 

12.000  

SUPPLEMENTAL CHILD/ADOLESCENT DRUG AND ALCOHOL SERVICES

12.101

Drug and Alcohol Intensive Case Management (Formerly, Targeted Case Management) For Children/Adolescents

 

13.000 OTHER ADULT MENTAL HEALTH SERVICES

13.100

Emergency/Crisis Services

 

13.101

Medical Mobile Crisis Team Service

 

13.102

23-Hour Assessment and Crisis Stabilization

 

13.103

23-Hour Crisis Observation, Evaluation, Holding, and Stabilization (Adult)

 

13.104
Non-Hospital Observation and Supervision  
13.200 Outpatient Treatment

13.201

Acute Partial Hospitalization

 

 14.000 OTHER CHILD AND ADOLESCENT MENTAL HEALTH SERVICES

14.100

Emergency/Crisis Services

 

14.101

23-Hour Crisis Observation, Evaluation, Holding, and Stabilization (Child / Adolescent)

 

14.102

Non-Hospital Observation and Supervision

 

14.103

Acute Partial Hospitalization

 

14.104

Medical Mobile Crisis Team Service

 

14.105
Multisystemic Therapy (MST)  
14.106
Functional Family Therapy (FFT) Service  
15.000 APPENDIX T
HEALTHCHOICES BEHAVIORAL HEALTH SERVICES
15.101

Guidelines for Mental Health Medical Necessity Criteria