Description
Treatment for behavioral health conditions is reimbursed according to the patient’s specific contract benefit language. Behavioral Health services may be performed at different levels of care to include: Inpatient hospital; Residential Treatment Center; Outpatient Facility-based Partial Hospitalization, Intensive Outpatient Program and Outpatient ECT; Outpatient TMS and Outpatient office.

Definitions:

Hospital: a short-term, acute care facility licensed as a hospital by the state in which it operates. A Hospital is primarily engaged in providing medical, surgical, or acute behavioral health diagnosis and treatment of injured or sick persons by or under the supervision of a staff of licensed Providers and continuous twenty-four (24) hour-a-day services by licensed, registered, graduate nurses physically present and on duty. The term Hospital does not include Long-Term Acute Care Hospitals; chronic care institutions or facilities that principally provide custodial, rehabilitative or long-term care, whether or not such institutions or facilities are affiliated with or are part of a hospital. A Hospital may participate in a teaching program. This means medical students, interns or residents participating in a teaching program may treat Members.   

Provider: any person or entity licensed by the appropriate state regulatory agency and legally entitled to practice within the scope of such person or entity’s license in the practice of any of the following: 

1. Medicine; 
2. Dentistry; 
3. Optometry; 
4. Podiatry; 
5. Chiropractic services; 
6. Behavioral health; 
7. Physical therapy; 
8. Oral surgery; 
9. Speech therapy; 
10. Occupational therapy; or, 
11. Osteopathy. 

The term Provider also includes a Hospital; a Rehabilitation Facility; a Skilled Nursing Facility; a physician assistant; nurses practicing in expanded roles (such as pediatric nurse practitioners, family practice nurse practitioners, psychiatric mental health nurse practitioners, and certified nurse midwives) when supervised by a licensed medical doctor or oral surgeon; and Behavioral Health Services when performed by a Behavioral Health Provider, licensed professional counselor, masters level licensed social worker, licensed marriage and family therapist or other licensed Behavioral Health Provider approved by the Corporation.  

The term Provider does not include interns, residents, physical trainers, lay midwives or masseuses, (When performed by a Provider or a Behavioral Health Provider within the scope of his or her license, training and specialty and within the scope of generally acceptable medical standards as determined by the Corporation)

Behavioral Health Provider: a Provider who renders Mental Health Services and/or Substance Use Disorder Services and is licensed to practice independently.

Behavioral Health Services: all Mental Health Services and/or Substance Use Disorder Services performed by a licensed Behavioral Health Provider.

Policy:

Crisis Stabilization Unit (EmPATH): a hospital unit that provides a care alternative to general emergency departments, inpatient admissions or use of law enforcement resources which meets all of the below requirements:

1. Located in a hospital that is licensed and accredited by the appropriate agency; 
2. Adhere to an Emergency Psychiatric Assessment, Treatment & Healing (EmPATH) philosophy and maintain active designation through SCDHHS;
3. Be located on the contiguous hospital campus grounds and linked to the emergency department for initial intake and/or referral;
4. The primary attending physician is a psychiatrist and/or addictionologist for Substance Use Disorder (SUD) admissions OR availability of a psychiatric consultant who performs an initial psychiatric assessment within 12 hours of admission and rounds on patients daily;
5. Be staffed at all times (24/7/365) to include a registered nurse and social worker. The multidisciplinary team should provide treatment that may include crisis care, therapy, peer support services, and education and use of coping activities.

Acute Inpatient Behavioral Health: a hospital or inpatient psychiatric unit which meets all four (4) of these requirements:

1. Licensed and accredited by the appropriate agency; 
2. The primary attending physician is a psychiatrist and/or addictionologist for Substance Use Disorder (SUD) admissions;  
3. The attending physician, psychiatric mental health nurse practitioner, or physician assistant is responsible for the clinical evaluation and provides daily face-to-face evaluation services with documentation or the facility is a network, contracting state-operated facility or verification of The Joint Commission accreditation for both the Behavioral Health Care Accreditation Program and the Hospital Accreditation Program is obtained; 
4. Registered nursing care on site, 24 hours per day, seven days per week, with full capabilities for intervention in behavioral health emergencies.

Residential Treatment Center (RTC): a licensed institution, other than a Hospital, which meets all seven (7) of these requirements:

1. Maintains permanent and full-time facilities for bed care of resident patients;
2. The facility is licensed OR accredited by the appropriate agency;
3. Has the services of a psychiatrist and/or addictionologist, for Substance Use Disorder (SUD) admissions, or psychiatric mental health nurse practitioner, or physician assistant available at all times and is responsible for the clinical evaluation and provides face-to-face evaluation services with documentation a minimum of once/week and as needed or as indicated; 
4. Has a registered nurse (RN) who oversees patient care on site a minimum of 8 hours/day 7 days a week and on call 24 hours per day/seven days per week. The response time to the facility must be 60 minutes or less when on call. Registered nursing personnel for residential facilities performing detoxification must be on site 24 hours/day seven days/week;
5. An awake licensed clinician must be on site 24/ hours/day seven days/week; 
6. Keeps a daily medical record for each patient; 
7. Is primarily providing a continuous structured therapeutic program specifically designed to treat behavioral health disorders and is not a group or boarding home, boarding or therapeutic school, half-way house, sober living residence, wilderness camp or any other facility that provides Custodial Care. 

Partial Hospitalization Program (PHP): an outpatient facility therapeutic treatment service which meets all six (6) of these requirements: 

1. Treatment at an outpatient facility level of care for a minimum of six hours per day, five days per week.  Exception for child and adolescents, total of 20 hours per week;
2. The facility is licensed OR accredited by the appropriate agency;
3. Has the services of a psychiatrist and/or addictionologist, for Substance Use Disorder (SUD) admissions, psychiatric mental health nurse practitioner, or physician assistant available at all times and is responsible for the clinical evaluation and provides face-to-face evaluation services with documentation a minimum of twice weekly and as indicated.  Exception for substance use treatment face-to-face evaluation services by the physician, psychiatric mental health nurse practitioner, or physician assistant at a minimum of once weekly and as indicated;
4. Direct access to nursing services during program hours;
5. Mental health and medical services are available 24 hours per day, seven days per week, as needed;
6. Licensed behavioral health practitioners supervise all treatment with appropriate documentation. 

Intensive Outpatient Program (IOP): an outpatient facility therapeutic treatment service which meets all five (5) of these requirements: 

1. Treatment at an outpatient facility level of care for a minimum of three days per week and nine total hours per week. Exception for child and adolescents, total of six hours per week;
2. The facility is licensed OR accredited by the appropriate agency.
3. Has the services of a psychiatrist and/or addictionologist, for Substance Use Disorder (SUD) admissions, psychiatric mental health nurse practitioner or physician assistant available at all times and is responsible for the clinical evaluation and provides face-to-face evaluation services with documentation a minimum of once per week and as indicated.  Exception for substance use treatment face-to-face evaluation services by the physician, psychiatric mental health nurse practitioner, or physician assistant is as clinically needed.
4. Mental health and medical services are available 24 hours per day, seven days per week, as needed.
5. Licensed behavioral health practitioners supervise all treatment with appropriate documentation.

Outpatient Electroconvulsive Therapy (ECT): an outpatient facility treatment service which meets all five (5) of these requirements:

1. The facility or unit is licensed and accredited by the appropriate state agency;
2. The primary attending physician is a psychiatrist. The attending is responsible for the clinical evaluation and provides face-to-face services with documentation;
3. Post ECT follow-up care is documented and updated to reflect changes in the clinical condition;
4. Mental health and medical services are available 24 hours per day, seven days per week, as needed;
5. Licensed behavioral health practitioners supervise all treatment with appropriate documentation.

Outpatient Transcranial Magnetic Stimulation (TMS): an outpatient treatment service which meets all five (5) of these requirements:

1. The TMS environment has features that allow all of the following: rapid access to the patient, immediate termination of pulsing, rapid removal of the coil from the patient and the ability to place the patient in a safe position for seizure management;
2. A physician available who is adequately trained and experienced in the specific TMS techniques being administered;
3. The facility must have a physician or nurse available who is trained in seizure management; 
4. An attendant trained in basic cardiac life support and the management of complications such as seizures, as well as the use of the equipment who is present at all times;
5. The facility must have an emergency plan in place to ensure access to Basic Life Support measures including the ability to monitor vital signs and awareness of response times of emergency services (either fire/ambulance or “code team”), which should be available within five (5) minutes. 

Outpatient Office Visits: an outpatient office therapeutic treatment service which meets both (2) of these requirements: 

1. Treatment is provided by either a licensed practitioner or a licensed accredited clinician and complies with generally accepted standards of care within the provider’s scope of training and licensure. 
2. Treatment at a frequency of greater than once per week may require documentation of current symptoms placing the member at a high risk of placement in a higher level of care.