Subsection 144-101-II-46.09 - ADMISSION ELIGIBILITY AND CONTINUING ELIGIBILITY CRITERIA Members must be determined eligible for admission and continued stay. Providers must maintain a member record for each member documenting the medical necessity for these services. Documentation must be available to the Department and its Authorized Agent. There must be daily documentation that the admission criteria continue to be met for the member to remain eligible for services unless otherwise noted.
46.09-1Psychiatric CriteriaMembers must meet all of the following four (4) criteria in order 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 criteria: a. 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.46.09-2Detoxification Criteria Members must meet the following criteria to be eligible for detoxification services.
The member's symptoms must meet American Society of Addiction Medicine's (ASAM) Level IV criteria as defined in the most recent edition of the ASAM Patient Placement Criteria (ASAM PPC-2R):
a. Member must have Substance -Use or Substance-Induced Disorder based upon DSM-IV TR; andb. Member must meet ASAM Level IV Dimensions 1, 2 or 3.46.09-3Developmental Disorders Unit CriteriaMembers under age 21 must meet the following four (4) criteria to qualify for Developmental Disorders Unit services:
1. A diagnosis of Mental Retardation or a Pervasive Developmental Disorder Axis I or II from the most current version of the Diagnostic and Statistical Manual of Mental Disorders; and2. A Global Assessment Functioning score of 35 or lower (this admission criteria does not need to be met as part of the continuing stay criteria); and3. Member's symptoms must be of such severity that they require intensive medical, psychiatric and nursing services; and one or both of the following: a. High frequency, intensity and duration of intervention is required to address repeated aggression or self-injury severe enough to have caused serious injury, or there is significant potential of serious injury to self or others; orb. Symptoms of Mental Retardation or Pervasive Developmental Disorder are of such severity that one is unable to care for oneself at a developmentally appropriate level, and treatment at a less restrictive level of care would be unsafe or is unavailable; and4. Member has not previously responded to a less restrictive level of care; or would have a significant risk of harm to self or others, or serious functional deterioration would occur, if a less restrictive setting was used. C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-46, subsec. 144-101-II-46.09