Okla. Admin. Code § 317:30-5-741 - Coverage by category
(a)
Adults. Behavioral health services in TFC settings are not covered
for adults.
(b)
Children. Behavioral health services are allowed in TFC settings
for children under twenty-one (21) as medically necessary. Members receiving
services in this setting have moderate behavioral and emotional health needs,
and may also present secondary physical, developmental, intellectual, and/or
social disorder that is supported alongside the mental health needs. The
designated members must continually meet medical necessity criteria to be
eligible for coverage in this setting. Requests for behavioral health services
in a TFC setting must be prior authorized and may be approved up to a maximum
of six (6) month extensions.
(c)
Medical necessity criteria. In order to satisfy medical necessity
criteria, all of the following conditions must be met:
(1) The member must have a diagnosis from the
Diagnostic and Statistical Manual of Mental Disorders (DSM-V), with the
exception of V codes and adjustment disorders, with a detailed description of
the symptoms supporting the diagnosis. Members with a provisional diagnosis may
receive TFC services for a maximum of thirty (30) days.
(2) An assessment must be completed by a
licensed behavioral health professional (LBHP) or licensure candidate as
defined in Oklahoma Administrative Code (OAC )
317:30-5-240.3(a) and
(b) within the thirty (30) day provisional
period described above, that confirms a diagnosis from the DSM-V with the
exception of V codes and adjustments disorders, and that includes a detailed
description of the symptoms supporting the diagnosis to continue treatment in a
TFC setting.
(3) Conditions are
directly attributed to moderate behavioral and emotional needs as the primary
need for professional attention.
(4) The current disabling symptoms could not
have been/have not been manageable in a less intensive treatment program, or
the level of care is warranted in order to reduce the risk of regression of
symptoms and/or sustain the gains made at a higher level of care.
(5) Evidence that the members' needs prohibit
full integration in a family/home setting without the availability of
twenty-four (24) hour crisis response/behavior management and clinical
interventions from professional staff, preventing the member from living in a
traditional family home.
(6) The
member is medically stable and not actively suicidal or homicidal and not in
need of substance abuse detoxification services.
(7) The legal guardian [Oklahoma Department
of Human Services (OKDHS )/ Oklahoma Office of Juvenile Affairs (OJA) if custody
member] or parent of the member agrees to actively participate in the member's
treatment needs and planning.
Notes
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