KMAP BULLETIN: Kansas Psychiatric Residential Treatment Facility (PRTF) Medical Necessity Criteria

Date: 10/30/20

KMAP BEHAVIOR MANAGEMENT/PRTF BULLETIN 20212 (PDF)

Effective with dates of service on and after November 1, 2020, the medical necessity criteria for clinical determination for PRTF admissions has been updated. The current process remains the same, however, updated admission criteria is being put in place.

A child or youth (referred to hereafter as ‘child’) needs a PRTF level of care when their psychiatric symptoms cause danger to themselves or others and intensive community services have failed to keep the child and others safe and have failed to improve their psychiatric condition or prevent regression.

EXCLUSIONS:

Any one of the following:

• Acutely suicidal or homicidal, acutely psychotic (unless the PRTF has the capacity to provide care in such situations, for example, 1:1 staffing, crisis management, 24/7 nursing and physician coverage), OR
• Acute substance use issues, OR
• Acute medical issues.

ADMISSION CRITERIA:

Child must meet A-E below:

1. Child must be under the age of 22.
2. Child’s current signs and symptoms meet criteria for a DSM diagnosis not solely due to Intellectual or Developmental Disability (IDD) and/or alcohol or drug use.
3. Community resources have been determined to not meet the current treatment needs of the child in the past 30 days, as evidenced by meeting ONE of the (1-2) below:
   1. The child’s Community-Based Services Team (CBST) or current treatment team believes that available intensive community services have been tried without sufficient success for at least 30 days, by meeting bullet a and b below:
      1. Child has participated in intensive community services for at least 30 days, including ALL the following:
         • Psychotherapies, such as individual, family and group psychotherapy
         • Psychiatric medication treatment
         • Rehabilitative services, such as Severe Emotional Disturbance (SED) waiver services, Psychosocial Rehab, Community Psychiatric Support and Treatment, etc.
      2. Intensive community services have not produced substantive improvement in the child’s behaviors and/or psychiatric symptoms.
   2. The child’s psychiatric and/or psychosocial condition prohibit the child from utilizing community services, by meeting ONE of the below:
      • Multiple inpatient admissions prohibit child from utilizing consistent community services.
      • Child has moved to different areas which makes utilizing consistent outpatient services problematic
      • Child’s behaviors/psychiatric condition are so severe they prohibit child from utilizing consistent community services.
      • The families, schools, or community’s efforts to manage the child’s behaviors have exhausted all available and accessible resources.
4. In the past 60 days, the child’s behaviors have caused multiple episodes of acute risk of substantial harm to self or others, or the child has been unable to care for their own physical health and safety so as to create a danger to their life, as evidenced by meeting TWO or more of the below in the past 60 days:
   • Aggressive or assaultive behavior causing substantial harm to self, others, animals, or property, unresponsive to adult de-escalation or direction
   • Unable to maintain behavioral control for more than 48 hours that may cause acute risk of substantial harm to self or others or substantial dysfunction in the community
   • Pervasive rejection of adult requests, directions, and rules that puts the child or others at risk for substantial harm or dysfunction in the home, school or community
   • Hostile, threatening or intimidating behavior resulting in fear response in others
   • Delusions/hallucinations/psychotic symptoms causing substantial dysfunction in daily living
   • Fire setting/repeated property destruction
   • Chronic non-suicidal, injurious behaviors
   • Chronic suicidal and/or homicidal ideas, plans and/or behaviors
   • Repeated arrests or confirmed illegal activity related to the psychiatric diagnosis that could place self/others at risk for substantial harm
   • Poor impulse control that does/could result in substantial harm to self or others and is unresponsive to adult intervention
   • Runaway that places self at risk for substantial harm
   • High-risk sexually inappropriate or abusive behavior
   • Support system unable or unavailable to manage intensity/safety regarding eating disorder symptoms
   • Substance use that exacerbates other psychiatric symptoms
5. PRTF services can be reasonably expected to improve the child’s chronic condition or prevent further regression so that services will no longer be needed, as evidenced by meeting at least ONE of the below:
   • PRTF treatment is expected to increase the child’s capacity to form therapeutic relationships and collaborate in their treatment, OR
   • PRTF treatment is expected to increase the child’s capacity to collaborate with their parents, teachers, coaches and other adults in their life, OR
   • PRTF treatment is expected to increase the child’s capacity to relate with peers in safe, satisfying and meaningful ways.

Note: Children who reside in a Qualified Residential Treatment Plan (QRTP) or are in Juvenile Department of Corrections (JDOC) custody would not be subject to all the above criteria as many of the described services are not available to these children.

Child must meet A-E below within the last two weeks:

1. Child must be under the age of 22
2. Child’s current signs and symptoms meet criteria for a DSM diagnosis not solely due to Intellectual or Developmental Disability (IDD) and/or alcohol or drug use.
3. There is a substantial chronic risk of harm to self or others, or the child is unable to care for his or her own physical health and safety so as to create a danger to the lives of self, others or animals, not manageable at a lower level of care, as evidenced by meeting at least ONE of the below in the past two weeks in any setting (e.g., facility, home, and community):
   • Aggressive or assaultive behavior causing harm to self, others, animals, or property
   • Hostile, threatening or intimidating behavior resulting in fear response in others
   • Poor or intrusive boundaries resulting in anger response in others and requiring frequent staff intervention
   • Requires intensive staff interventions to co-regulate and/or contain emotional dysregulation and prevent substantial harm to self or others
   • Requires external controls to prevent impulsiveness that would put self or others at risk of substantial harm
   • Requires external controls to care for his/her own physical health and safety and prevent significant illness or injury
   • Treatment-rejecting behavior that would represent a barrier to treatment in the community
   • Pervasive rejection of adult requests, directions, and rules that puts the child or others at risk for substantial harm or dysfunction in the home, school or community
   • Pervasive suicidal or homicidal ideation and/or action that puts the child or others at risk for substantial harm
   • Delusions/hallucinations/psychotic symptoms impacting daily living
   • The psychiatric medication regimen is still being adjusted to address symptoms, side effects, and manageability in the community that cause risk of harm or otherwise prevent successful return to the community
4. PRTF services can be reasonably expected to produce clinically significant improvement in the child’s chronic condition or prevent further regression so that services will no longer be needed, and positive impacts of continued stay outweigh the negative impacts, including separation of the child and family.
5. Clinical best practices are being provided with sufficient intensity to address the child’s treatment needs and meet regulatory requirements.
6. Prior to discharge, the PRTF team has collaborated directly with community providers to facilitate successful transition of care.

Note: The effective date of the policy is November 1, 2020. The implementation of State policy by the KanCare managed care organizations (MCOs) may vary from the date noted in the Kansas Medical Assistance Program (KMAP) bulletins. The KanCare Open Claims Resolution Log on the KMAP Bulletins page documents the MCO system status for policy implementation and any associated reprocessing completion dates, once the policy is implemented.