Okla. Admin. Code § 317:30-5-241.10

Current through Vol. 42, No. 4, November 1, 2024

Section 317:30-5-241.10 - Partial hospitalization program (PHP) - Adults

(a)Definition. PHP is an intensive nonresidential, structured therapeutic treatment for individuals with substance use disorder, mental health diagnoses, and/or co-occurring disorders. It can be used as an alternative to and/or a step-down from inpatient or residential treatment, or to stabilize a deteriorating condition that may result in a need for inpatient or residential care. PHP services are:

(1) Reasonable and necessary for the diagnosis or active treatment of the individual's condition; and

(2) Reasonably expected to improve the individual's condition and functional level and to prevent relapse or hospitalization/residential care.

(b)Eligibility criteria. This service must be prior authorized by OHCA or its designated agent, and individuals must meet ongoing medical necessity criteria. Treatment is time limited, and length of participation is based on the individual's needs.

(c)Eligible providers. Provider agencies for PHP must be accredited to provide partial hospitalization services by The Joint Commission (TJC), the Commission on Accreditation of Rehabilitation Facilities (CARF), the Accreditation Commission for Health Care (ACHC) or The Council on Accreditation (COA) and enrolled in SoonerCare. The staff providing PHP services are employees or contractors of the enrolled agency. The agency is responsible for ensuring that all services are provided by properly credentialed clinicians.

(d)Qualified practitioners. Program services are overseen by a psychiatrist. The number of professionals and paraprofessionals required on the clinical team is dependent on the size of the program. The clinical team includes the following required professionals:

(1) A licensed physician, physician's assistant, or advanced practice registered nurse [any of whom meet the requirements of an LBHP as described at OAC 317:30-5-240.3(a)] ;

(2) A registered nurse; and

(3) One (1) or more LBHPs or licensure candidates listed in OAC 317:30-5-240.3(a) and (b).

(4) The clinical team may also include a certified behavioral health case manager.

(e)Service components. PHP service components include the following, provided by qualified professionals:

(1) Behavioral health/alcohol and drug assessment;

(2) Behavioral health/alcohol and drug service plan development;

(3) Individual/family/group therapy for behavioral health and/or substance abuse;

(4) Psychosocial rehabilitation services/substance abuse skills development (individual and group);

(5) Medication training and support;

(6) Case management;

(7) Crisis intervention services must be available twenty-four (24) hours a day, seven (7) days a week.

(f)Limitations. Treatment is time limited, based on medical necessity, and must offered at a minimum of three (3) hours per day, five (5) days a week. PHP cannot be billed in conjunction with the following services:

(1) Inpatient/residential psychiatric or residential substance use disorder services;

(2) Individual/family/group therapy for behavioral health; and/or substance abuse;

(3) Psychosocial rehabilitation services/substance abuse skills development (individual and group);

(4) Targeted case management (TCM);

(5) Mobile crisis intervention provided within the PHP setting;

(6) Peer recovery support;

(7) Program of Assertive Community Treatment (PACT);

(8) Certified Community Behavioral Health (CCBH) services.

(g)Non-covered services. The following services are not considered PHP and are not reimbursable:

(1) Room and board;

(2) Educational costs;

(3) Services to inmates of public institutions;

(4) Routine supervision and non-medical support services in school settings;

(5) Child care;

(6) Respite;

(7) Personal care.

(h)Documentation requirements. Documentation needs to specify active involvement of the member. A nursing health assessment must be completed within twenty-four (24) hours of admission. Service plan updates are required every three (3) months or more frequently based on clinical need. Records must be documented according to OAC 317:30-5-248.

(i)Staffing requirements. Staffing must consist of the following:

(1) A registered nurse (RN) trained and competent in the delivery of behavioral health services as evidenced by education and/or experience that is available on-site during program hours to provide necessary nursing care and/or psychiatric nursing care [one (1) RN at a minimum can be backed up by a licensed practical nurse (LPN) but an RN must always be on site];

(2) Medical director must be a licensed psychiatrist;

(3) A psychiatrist/physician must be available twenty-four (24) hours a day, seven (7) days a week; and

(4) One (1) or more LBHPs or licensure candidates listed in OAC 317:30-5-240.3(a) and (b).

(j)Reimbursement. PHP services are reimbursed pursuant to the methodology described in the Oklahoma Medicaid State Plan. PHP reimbursement is all-inclusive of the service components, except for the following:

(1) Physician services;

(2) Medications;

(3) Psychological testing by a licensed psychologist.

Okla. Admin. Code § 317:30-5-241.10

Adopted by Oklahoma Register, Volume 39, Issue 24, September 1, 2022, eff. 9/12/2022