C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-46, subsec. 144-101-II-46.05
All covered services are subject to Utilization Review as set forth in Section 46.08, and all covered services must be medically necessary, as defined in Chapter I, Section 1.
Covered services include those services ordinarily provided in a psychiatric hospital for the twenty four (24) hour care and treatment of an inpatient under the supervision of a psychiatrist and in accordance with the member's plan of care.
Partial hospitalization services must be designed to meet the treatment and rehabilitative needs of the member as identified in a treatment plan. Services include, but need not be limited to, individual, group and activities components designed to develop members' emotional and physical capability in areas of daily living, community integration and interpersonal functioning. Outpatient services include but need not be limited to: diagnosis and assessment; individual, family and group therapy; medication evaluation, education and monitoring; stress management; and daily living skills training services.
Outpatient Services are professional assessment, counseling and therapeutic services provided to members to relieve excess stress and promote positive orientation and growth toward more integrated and independent levels of functioning. Services are delivered through planned interaction involving the use of physiological, psychological, and sociological concepts, techniques and processes of evaluation and intervention.
Services include diagnosis and assessment, psychometric evaluation, intervention services by psychological examiners, individual, group, and family therapy, specialized treatment for sexual abuse victims or offenders, medication review and chemotherapy, and similar professional therapeutic services. Services must include a direct encounter with the member. Services must focus on the special developmental and emotional needs and problems of the member where appropriate.
In order to be eligible for reimbursement the need for services must be documented in the treatment plan and is subject to approval and Utilization Review by the Department and its Authorized Agent according to guidelines set forth in Section 46.08.
C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-46, subsec. 144-101-II-46.05