Subsection 144-101-II-45.09 - ADMISSION ELIGIBILITY AND CONTINUING ELIGIBILITY CRITERIA FOR PSYCHIATRIC UNIT AND DETOXIFICATION SERVICESMembers must be determined eligible for admission and continued stay. Providers must maintain a member record for each member documenting the medical necessity for psychiatric unit services. Documentation must be available to the Department and its Authorized Agent. There must be daily documentation that the admission criteria continues to be met for the member to remain eligible for services.
45.09-1Psychiatric CriteriaMembers must meet all four (4) of the following criteria to be eligible for psychiatric unit services, and must continue to meet all four (4) of the following criteria in order to continue to be eligible for psychiatric services:
1. The member has a substantiated diagnosis found in the most current version of the American Psychiatric Association's Diagnostic and Statistical Manual (DSM).2. Treatment is medically necessary. Medical necessity must include one (1) or more of the following: a. The member exhibits an immediate or direct threat of serious harm to self or there is a clear and reasonable inference of serious harm to self, where suicidal precautions or observations on a 24-hour/day basis are required. This behavior must require intensive psychiatric, medical and nursing treatment interventions on a 24-hour day basis.b. The member is exhibiting an immediate or direct threat of serious harm to others or there is evidence for clear and reasonable inference of serious harm to others. This behavior must require intensive psychiatric, medical and nursing treatment interventions on a 24-hour/day basis.c. The member is exhibiting an extreme disabling condition such that one cannot take care of self in a developmentally appropriate level or requires assistance beyond the home or residential setting. The member's symptoms must be of such severity that they require 24-hour/day intensive medical, psychiatric, and nursing services. Outpatient treatment would be clearly unsafe or is unavailable. A lower level of care is not available or would not be adequate to successfully treat those symptoms.3.Age specific criteriaa. For members under the age of twenty-one (21) or adults with a legal guardian:i. The member's family / guardian(s), where applicable and clinically indicated, are willing to actively participate throughout the duration of treatment.ii. The services can reasonably be expected to improve the member's condition or prevent further regression so that inpatient services will no longer be needed.b. For members age sixty-five (65) or older, services are the only alternative available to maintain or restore the member to the greatest possible degree of health and independent functioning.4. A clear indication that the inpatient psychiatric services offered provide the member with active treatment.45.09-2Detoxification CriteriaMembers must meet the following criteria to be eligible for detoxification services.
The member's symptoms must meet American Society of Addiction Medicine (ASAM) Level 4 criteria as defined in the most recent edition of The ASAM Criteria: Treatment Criteria for Addictive, Substance-related, and Co-Occurring Conditions:
a. Member must have Substance - Use or Substance-Induced Disorder based upon DSM-5; andb. Member must meet ASAM Level 4 Dimensions 1, 2, or 3. C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-45, subsec. 144-101-II-45.09