Outpatient Psychiatric Services Definition and Eligibility Requirements

Service Definition

Outpatient psychiatric services are provided in a practitioner’s office, mental health clinic, individual’s home, or nursing facility. If services are provided in a setting other than the office or a clinic, this must be documented. Services shall be medically prescribed treatment, which is documented in an active written treatment plan designed, signed, and dated by the professionally licensed, Medicaid enrolled qualified provider. Psychiatric services require a plan of care.

Medical Necessity Criteria

Magellan defines medical necessity as: "Services by a provider to identify or treat an illness that has been diagnosed or suspected. The services are: 1. consistent with the diagnosis and treatment of a condition and the standards of good medical practice; 2. required for other than convenience; and 3. the most appropriate supply or level of service.

Individuals must meet both Criteria A and B to qualify for reimbursement.

Criteria for Participation

In order for a recipient to qualify to receive outpatient psychiatric services, the recipient must meet all of the following criteria:

Criteria B

Individuals must meet one of the following criteria: