Outpatient Psychiatric Services Definition and Eligibility Requirements
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:
Requires treatment in order to sustain behavioral or emotional gains or to restore cognitive functional levels, which have been impaired;
Exhibits deficits in peer relations, deficits in dealing with authority, hyperactivity, poor impulse control, clinical depression, or demonstrates other dysfunctional symptoms having an adverse impact on attention and concentration, the ability to learn, or the ability to participate in employment, educational, or social activities;
Is at risk for developing or requires treatment for maladaptive coping strategies; and
Presents a reduction in individual adaptive and coping mechanism or demonstrates extreme increase in personal distress.
Individuals must meet one of the following criteria:
- Have experienced long-term or repeated psychiatric hospitalizations; or
- Experience difficulty in activities of daily living and interpersonal skills; or
- Have a limited or non-existent support system; or
- Be unable to function in the community without intensive intervention; or
- Require long-term services to be maintained in the community.