Inpatient/partial hospitalization evaluations
When a member is admitted to an inpatient or partial hospital setting for behavioral health treatment, ongoing clinical reviews are completed to determine if that member still meets medical necessity criteria for treatment. If the criteria are questionable, the case will be presented to a Priority Health Physician Advisor for a doctor-to-doctor review.
| Inpatient/partial hospital medical necessity criteria |
|---|
- Treatment plan
- Anticipated length of stay
- Discharge planning
- Current medications
- Changes made to medications since the last review
- Symptoms
- Behaviors
- Functioning status
- High risk factors
|
Intake assessment
- Brief description/action:
- Are you currently, or any time in the last 3 months, having thoughts about harming yourself? (yes or no)
- Are you currently, or at any time in the past 3 months, having thoughts about harming someone else? (yes or no)
- Do you hear things or see things that others do not? (yes or no)
- Are you currently experiencing any physical discomfort related to the use of alcohol or drugs? (yes or no)
If the patient is covered by Medicaid, ask the following additional screening questions:
- Are you currently receiving services through Community Mental Health? (yes or no)
- Have you ever been case managed or received services through Community Mental Health? (yes or no)
- Have you been hospitalized in a psychiatric setting within the past 2 years? (yes or no)
Concurrent review
- Type of review:
- Date of review:
- Attending physician:
- Caller:
- Facility:
- Is the member on medication?
- Acute suicidal ideation with plan/intent?
- Acute homicidal ideation with plan/intent?
- Acute psychosis?
- Acute detox symptomatology?
- Signs and symptoms of acute risk factors?
- Medications; dosage and frequency
- Does member meet medical necessity criteria?
- Further treatment authorized?
- Send to physician review?
Discharge report questions - Initial level of care:
- Step-down level of care:
- Caller:
- Facility information:
- Discharge date:
- Is the member on medication?
- Axis I diagnoses:
- Axis II diagnoses:
- Axis III diagnoses:
- Axis IV diagnoses:
- Axis V diagnoses:
- Medications; dosage and frequency:
- Was there an aftercare appointment set up within 7 days?
- Rationale for no aftercare appointment within 7 days:
- Member is member being discharged to: partial, intensive outpatient, or outpatient level of care?
- Aftercare appointments; provider/facility name(s), location, date(s), time(s):
Go to detailed medical necessity criteria for inpatient psychiatric/substance use and/or partial psychiatric hospitalization.
