Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 40 - PSYCHIATRIC RESIDENTIAL TREATMENT FACILITIES › Section 40-7 - Admission

Current through July 13, 2024
(a) Before admission to a facility, an
				interdisciplinary team shall complete a certification of need for services in
				accordance with 42 CFR
				§
										441.154.
(b) Admission Certification. Admissions to
				PRTFs are subject to the prior authorization procedures outlined in Section
				8 of this Chapter. The Department shall
				determine the medical necessity of admission to an PRTF using the following
				criteria:
(i) The client presents with a
				longstanding (at least six months) psychiatric diagnosis characterized by
				severely distressing, disruptive or immobilizing symptoms that are persistent
				and pervasive, and which cannot be reversed with treatment in an outpatient
				treatment setting, or is being stepped down in intensity from an acute
				psychiatric facility. The diagnosis shall meet the criteria for an Axis 1 as
				defined by the current edition of the Diagnostic and Statistical Manual of
				Mental Disorders (DSM);
(ii) There
				are documented attempts to treat the client with the maximum intensity of
				services available at a less intensive level of care that cannot meet or has
				failed to meet the needs of the client within the past six (6) months. The
				client shall have failed to respond to outpatient interventions. Six (6) months
				of alternative, less restrictive levels of care shall have been tried and have
				failed, or are not psychiatrically indicated;
(iii) At least one of the patterns of
				behavior listed below must be present:
(A)
				Persistent, pervasive and frequently occurring oppositional/defiant
				behavior;
(B) Reckless or impulsive
				behavior, which represents a disregard for the well-being or safety of
				self/others;
(C) Aggressiveness or
				explosive behavior;
(D) Gestures
				with intent to injure self/others, which have not resulted in serious injury,
				without evidence that such gestures are immediately progressing to life
				threatening behavior;
(E)
				Self-induced vomiting, use of laxatives/diuretics, strict dieting, fasting
				and/or vigorous exercise;
(F)
				Extreme phobic/avoidant behavior;
(G) Extreme social isolation; or
(H) History of repeated life threatening
				injury to self/others, resulting in acute care admissions within the past
				twelve (12) months. The client is not currently considered at risk to inflict
				life-threatening injury to self/others in the residential treatment
				setting.
(iv) Without
				intervention, there is clear evidence that the client will likely decompensate
				and present a risk of serious harm to self or others; or
(v) A psychiatric evaluation by a board
				certified child/adolescent psychiatrist. The child/adolescent psychiatrist must
				be licensed, board certified, and in good standing. The child/adolescent
				psychiatrist must be independent of the PRTF being considered for admission. If
				the child/adolescent psychiatrist works for the PRTF being considered for
				admission, a second opinion must be obtained from the agency contracted by the
				Division for such services. The evaluation must take place no more than
				forty-five (45) days prior to PRTF Admission.