Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 84 - INTENSIVE TREATMENT FAMILY CARE › Section 317:30-5-751 - Coverage by category

Current through Vol. 41, No. 20, July 1, 2024
(a)
Adults.
Behavioral health services in ITFC settings are not
				  covered for adults.
(b)
Children.
Behavioral health services are allowed in ITFC settings
				  for children under twenty-one (21) as medically necessary. Members receiving
				  services in this setting have severe behavioral and emotional health needs and
				  may also present a secondary physical, developmental, intellectual, and/or
				  social disorder that is supported alongside the mental health needs. ITFC homes
				  provide the higher level of care needed for these children and help prevent
				  placement in an inpatient or more restrictive setting. The designated members
				  must continually meet medical necessity criteria to be eligible for coverage in
				  this setting. Requests for behavioral health services in an ITFC setting must
				  be prior authorized and may be approved up to a maximum of three (3) 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 ITFC services for a
				  maximum of thirty (30) days.
(2)
				  An assessment must be completed by a licensed behavioral health professional
				  (LBHP) as defined in Oklahoma Administrative Code (OAC)
				  317:30-5-240.3(a)
				  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 an ITFC setting.
(3) Conditions are directly attributed to a
				  primary medical diagnosis of a severe behavioral and emotional health need, and
				  may also be attributed to a secondary medical diagnosis of a physical,
				  developmental, intellectual and/or social disorder that is supported alongside
				  the mental health needs.
(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 intensive clinical interventions from professional staff,
				  preventing the member from living in a traditional or therapeutic foster 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.