This 424-page manual provides behavioral health medical review policies, ‘benefit interpretations’ criteria, benchmarks and guidelines for inpatient, day hospital, residential and outpatient care. A practical model for a quality-based and cost-effective care management approach as well as coverage determinations. The manual also contains numerous policies, procedures, tools and forms vital to prepare for accreditation or certification surveys and strategies for quality-based efficient delivery of integrated behavioral health care. Also included are references and web site links. This manual is updated annually.

Contents Includes:

• Managed behavioral health care – Introduction; Medicare payment for part B Mental Health Services; Managing behavioral health care; Psychiatric Consultation and Care; Integration of care/Collaborative care; Group therapy; Medical Necessity defined; Health and Behavioral Intervention Services; Brief therapy or short-term therapy; Behavioral Health Benefits; Telehealth benefit; Evidence for a ‘chronic’ diagnosis; mental health benefit interpretation examples; typical behavioral health limitations/exclusions;
• Behavioral/Mental Health Services Coverage, general – Court ordered mental health services; Pathologic gambling; List of non-covered conditions/treatments; Eye movement desensitization and reprocessing (EMDR) therapy; Marital counseling, ‘72 hour hold’ admissions;

  Psychotherapy:Psychotherapy, introduction, coverage considerations; Family Medical Psychotherapy; Group Psychotherapy; Interactive Group Medical Psychotherapy; Hypnosis/Hypnotherapy; Individual psychotherapy, insight oriented, behavior modifying, and/or supportive; Interactive Individual Psychotherapy; Narcotherapy;

  Testing: Psychological testing; Neuropsychological Testing; Developmental skills testing; Screens;‘Rebirthing techniques’; Autism, Lovaas therapy for the management of; Brain mapping or quantitative EEG for the diagnosis of psychiatric disorders; Stereotactic Cingulotomy; Court ordered mental health services; Developmental skills testing; Dyslexia; Electroconvulsive therapy (ECT); Family Medical Psychotherapy; Group Psychotherapy; Interactive Group Medical Psychotherapy; Hypnosis/Hypnotherapy; Individual psychotherapy, insight oriented, behavior modifying, and/or supportive; interactive psychotherapy; Interactive Individual Psychotherapy; Home Health - Skilled Care for Psychiatric Services; Learning disabilities; Play therapy; Psychiatric Diagnostic Interview; Psychiatric Pharmacotherapy; Psychological testing; Social services, outpatient; Transition of behavioral health care services;

• Behavioral health treatment programs – BH treatment plans; Triage with screening form; Outreach - monitoring the course of therapy; Provider issues, compensation; Treatment plan and authorization form.
• Provider issues – Access standards; therapy goals; behavioral health staffing; productivity of BH staff; patient management ‘control’ issues; provider profiles; provider compensation.
• Utilization/Quality Management and Improvement – Accreditation/certification; Quality Indicators; UM/QI example plan; Performance Improvement Measures; Readmission Rates; UR Benchmarks; Utilization management; Medication;
• Admission and Discharge criteria for Mental Health Disorders, other than drug detoxification – Inpatient criteria; Observation status; Support network considerations; Intensity of service/Severity of illness criteria; Severity of illness criteria justifying acute inpatient therapy; Age-related considerations; Hospital care reviews; Review for continued medical necessity; Day/Partial treatment programs; Retrospective review; Criteria not justifying inpatient admission; Criteria justifying discharge; Case Management; Discharges Against Medical Advice (‘AMA’)..
• Disease State Management/Therapy, review criteria – Special populations - Geriatric, Childhood and Adolescent issues; Therapeutic preschool; Residential treatment center; Case Management - Policies, Procedures, 'Red Flags', Triggers.
• Review Criteria and Case Management Guidelines, by disease state – Alcohol/Chemical Dependency/Substance Abuse; Detoxification – includes: outpatient, Detoxification – inpatient, Continued stay criteria, Discharge criteria; Chemical Aversion Therapy; Electrical Aversion Therapy; Treatment of Alcoholism and Drug Abuse in a Freestanding Clinic; Treatment of Drug Abuse (Chemical Dependency); Methadone treatment; Childhood and adolescent treatment; Inpatient Hospital Stays for the Treatment of Alcoholism; Outpatient Hospital Services for Treatment of Alcoholism; Alcohol and drug rehabilitation centers; Criteria for admission to a substance abuse rehabilitation program, ‘Open access’ referral P & P for chemical dependency, Chemical dependency benchmarks; Web resources; Eating Disorders - Anorexia nervosa, Bulimia nervosa, Residential and outpatient treatment criteria for eating disorders; Obesity; Web resources;

  Schizophrenic disorders, Delusional disorders; Mood Disorders - Depressive disorders; Cognitive Behavioral Therapy; Transcranial Magnetic Stimulation (TMS); Bipolar Disorders; Anxiety, Phobias and Somatoform Disorders - Anxiety disorders, Panic disorder, Anxiety disorders of childhood or adolescence; Post-traumatic stress disorder; Obsessive compulsive disorder; Somatoform disorders; Dissociative Disorders; Personality Disorders; Adjustment Disorders; Impulse-Control Disorders, not otherwise classified: Intermittent explosive disorder, Conduct Disorders, Oppositional defiant disorder, Attention Deficit/Hyperactivity Disorders; Cognitive/Mental disorders d/t general medical condition, children, adolescents; web resources.

• Utilization management/Contractual issues – Authorization procedures; Authorization Process, forms; Discharge Summary Format; Encounter Form for Providers; Case Management policy and procedures; Continued Stay Review Form; Utilization Benchmark Data; Referral authorization form examples; Other forms related to UM/QM.
• Medical/Behavioral Health Records– Behavioral Health Patient Information Intake form; Acknowledgment form for new patients; Medical Records Release - policy and procedures, example forms; Psychotherapy notes; Psychiatry Summary Information Form for Primary Physician; JCAHO Medical Record Review Form; Web resources.
• Quality Management - QM/QI Work Plan, annual with list; Patient satisfaction survey form; Quality Management Policy and Procedures; Quality ‘red flags/indicators; operational standards; Access to care (appointments, in-office wait times) policies and procedures; QM Special Access Audit; QM/QI Committee policies and procedures: membership, agendas, minutes; Patient’s Rights and Responsibilities Statements.
• Consent forms – Introduction, capacity to consent; Consents for treatment (adult, child), Audio/videotaping release; Standard introduction to consent statement for any consent; Non-covered services disclosure format; Treatment of child by Psychiatrist release form; Confidentiality Agreement; Employee/staff Non-disclosure Agreement; Permission to contact form; Non-covered services disclosure format; Consent to release/exchange information; Employee/staff non-disclosure agreement; Permission to Contact form; other forms.
• Addenda – Contract to provide capitated behavioral health care services – example; CMS Pub 09 Rehabilitation Manual, Section 260. Partial Hospitalization Coverage Criteria for Medicare; CMS Pub 10 Hospital Manual, Section 212. Psychiatric admission coverage criteria for Medicare.
• Glossaries – Glossary National Associations/Organizations For Health Care; BH review firms, ‘Carve-outs’; Accreditation/Certification for Behavioral Health Care Organizations; Consultants; Accreditation readiness check lists.
• References and resources – Extensive literature references are listed by condition or issue throughout and in this section of the manual.

**Updated Annually**