Okla. Admin. Code § 317:30-5-95.29

Current through Vol. 41, No. 19, June 17, 2024

Section 317:30-5-95.29 - Medical necessity criteria Acute II and PRTF admissions for children

Acute II and PRTF admissions for individuals under twenty-one (21) must meet the terms and conditions in (1), (2), (3), (4), (5) and one (1) of the terms and conditions of (6)(A) through (D) of this subsection.

(1) A primary diagnosis from the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) with the exception of V-codes, adjustment disorders, and substance-related disorders, accompanied by detailed symptoms supporting the diagnosis. Members eighteen (18) to twenty (20) years of age may have a diagnosis of any personality disorder. Adjustment or substance-related disorders may be a secondary diagnosis.

(2) Conditions are directly attributed to a mental disorder as the primary reason for professional attention (this does not include placement issues, criminal behavior, or status offenses).

(3) Patient has either received treatment in an acute setting or it has been determined by the OHCA, or its designated agent, that the current disabling symptoms could not or have not been manageable in a less-intensive treatment program.

(4) Member must be medically stable.

(5) Requires twenty-four (24) hour observation and treatment as evidenced by:

(A) Intensive behavioral management;

(B) Intensive treatment with the family/guardian and child in a structured milieu; and

(C) Intensive treatment in preparation for re-entry into community.

(6) Within the past fourteen (14) calendar days, the patient has demonstrated an escalating pattern of self-injurious or assaultive behaviors as evidenced by any of (A) through (D) below. Exceptions to the fourteen (14) day requirement may be made in instances when evidence of the behavior could not have reasonably been discovered within fourteen (14) days (e.g., sexual offenses).

(A) Suicidal ideation and/or threat.

(B) History of/or current self-injurious behavior.

(C) Serious threats or evidence of physical aggression.

(D) Current incapacitating psychosis or depression.

Okla. Admin. Code § 317:30-5-95.29

Added at 23 Ok Reg 2508, eff 6-25-06 ; Amended at 27 Ok Reg 2737, eff 7-20-10 (emergency) ; Amended at 28 Ok Reg 1452, eff 6-25-11 ; Amended at 29 Ok Reg 413, eff 3-7-12 (emergency) ; Amended at 29 Ok Reg 1125, eff 6-25-12 ; Amended at 30 Ok Reg 1203, eff 7-1-13

Amended by Oklahoma Register, Volume 31, Issue 24, September 2, 2014, eff. 9/12/2014

Amended by Oklahoma Register, Volume 37, Issue 24, September 1, 2020, eff. 9/14/2020

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