Admission Criteria

 

Mental health skill-building services are defined as goal-directed training to enable individuals to achieve and maintain community stability and independence in the most appropriate, least restrictive environment. MHSS must include goal-directed training in the following areas in order to qualify for reimbursement: functional skills and appropriate behavior related to the individual’s health and safety; activities of daily living, and use of community resources; assistance with medication management; and monitoring health, nutrition, and physical condition. Providers shall be reimbursed only for training activities related to these areas, and only where services meet the revised service definition, service eligibility, and service provision criteria and guidelines as described in the regulations 

Medical Necessity Criteria

An Independent Clinical Assessment must be conducted by the CSB/BHA prior to the authorization of new service requests for MHSS services for dates of service beginning on or after July 18, 2011. New services are defined as services for which the individual has been discharged from or never received prior to July 17, 2011. For adult members 21 and older an Independent Clinical Assessment is not required.

Individuals qualifying for Mental Health Skill-building Services must demonstrate a clinical necessity for the service arising from a condition due to a mental, behavioral, or emotional illness that results in significant functional impairments in major life activities. Services are provided to individuals who require individualized training to achieve or maintain stability and independence in the community.

Individuals age 21 and over must meet all of the following criteria in order to be eligible to receive mental health skill-building services:

CRITERIA A

The individual must have one of the following as a primary Axis I DSM diagnosis:

  1. Schizophrenia or other psychotic disorder as set out in the DSM,
  2. Major Depressive Disorder – Recurrent;
  3. Bipolar I; or Bipolar II;
  4. Any other Axis I mental health disorder that a physician has documented specific to the identified individual within the past year to include all of the following:
    1. that is a serious mental illness;
    2. that results in severe and recurrent disability;
    3. that produces functional limitations in the individual’s major life activities that are documented in the individual’s medical record, AND;
    4. that the individual requires individualized training in order to achieve or maintain independent living in the community.

CRITERIA B

The individual shall require individualized training in acquiring basic living skills such as symptom management; adherence to psychiatric and medical treatment plans; development and appropriate use of social skills and personal support system; personal hygiene; food preparation; or money management.

CRITERIA C

The individual shall have a prior history of any of the following: psychiatric hospitalization; residential crisis stabilization, ICT or Program of Assertive Community Treatment (PACT) services; placement in a psychiatric residential treatment facility (RTC Level C); or TDO pursuant to the Code of Virginia §37.2- 809(B) evaluation as a result of decompensation related to serious mental illness. This criterion shall be met in order to be initially admitted to services, and not for subsequent authorizations of service.

CRITERIA D

The individual shall have had a prescription for anti-psychotic, mood stabilizing, or antidepressant medications within the 12 months prior to the assessment date. If a physician or other practitioner who is authorized by his license to prescribe medications indicates that anti-psychotic, mood stabilizing, or antidepressant medications are medically contraindicated for the individual, the provider shall obtain medical records signed by the physician or other licensed prescriber detailing the contraindication. This documentation shall be maintained in the individual’s mental health skill-building services record, and the provider shall document and describe how the individual will be able to actively participate in and benefit from services without the assistance of medication. This criterion shall be met upon admission to services, and not for subsequent authorizations of service.