Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 6 - INPATIENT PSYCHIATRIC AND SUBSTANCE USE DISORDER SERVICES › Section 317:30-5-95.1 - Medical necessity criteria and coverage for adults aged twenty-one (21) to sixty-four (64)

Current through Vol. 41, No. 20, July 1, 2024
(a)
Coverage
				  for adults.
Coverage for adults aged twenty-one (21) to sixty-four (64)
				  is limited to services in a psychiatric unit of a general hospital or in a
				  psychiatric hospital (see OAC
				  317:30-5-95)
				  . Inpatient psychiatric services must be prior authorized in accordance with
				  OAC
				  317:30-5-41.1.
				  OHCA rules that apply to inpatient psychiatric coverage for adults aged
				  twenty-one (21) to sixty-four (64) are found in Sections OAC 317:30-5-95.1
				  through
				  317:30-5-95.10.
(b)
Medical necessity
				  criteria for admission of adults aged twenty-one (21) to sixty-four (64) for
				  psychiatric disorders.
An inpatient admission of an adult aged
				  twenty-one (21) to sixty-four (64) that is attributable to a psychiatric
				  disorder must meet the terms or conditions contained in (1), (2), (3), (4), one
				  of (5)(A) to (5)(D), and one of (6)(A) to (6)(C) of this subsection.
(1) A primary diagnosis from the most recent
				  edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) with
				  the exception of V-codes, adjustment disorders, and substance related
				  disorders, accompanied by a detailed description of the symptoms supporting the
				  diagnosis.
(2) Conditions are
				  directly attributable to a psychiatric disorder as the primary need for
				  professional attention (this does not include placement issues, criminal
				  behavior, and/or status offenses). Adjustment or substance related disorder may
				  be a secondary diagnosis.
(3) It
				  has been determined by the OHCA designated agent that the current disabling
				  symptoms could not have been managed or have not been manageable in a less
				  intensive treatment program.
(4)
				  Adult must be medically stable.
(5)
				  Within the past forty-eight (48) hours, the behaviors present an imminent
				  life-threatening emergency such as evidenced by:
(A) Specifically described suicide attempts,
				  suicidal intent, or serious threat by the patient.
(B) Specifically described patterns of
				  escalating incidents of self-mutilating behaviors.
(C) Specifically described episodes of
				  unprovoked significant physical aggression and patterns of escalating physical
				  aggression in intensity and duration.
(D) Specifically described episodes of
				  incapacitating depression or psychosis that result in an inability to function
				  or care for basic needs.
(6) Requires secure twenty-four (24) hour
				  nursing/medical supervision as evidenced by:
(A) Stabilization of acute psychiatric
				  symptoms.
(B) Needs extensive
				  treatment under physician direction.
(C) Physiological evidence or expectation of
				  withdrawal symptoms which require twenty-four (24) hour medical supervision.