(1) Medicaid reimbursement is not available for outpatient partial hospitalization services unless the provider submits to the department or its designee in accordance with these rules a complete and accurate Certificate of Need, certifying that:

(a) the recipient is experiencing psychiatric symptoms of sufficient severity to create severe impairments in educational, social, vocational, and/or interpersonal functioning;

(b) the recipient cannot be safely and appropriately treated or contained in a less restrictive level of care;

(c) proper treatment of the beneficiary's psychiatric condition requires acute treatment services on an outpatient basis under the direction of a physician;

(d) the services can reasonably be expected to improve the recipient's condition or prevent further regression; and

(e) the recipient has exhausted or cannot be safely and effectively treated by less restrictive alternative services, including day treatment services or a combination of day treatment and other services.

(2) Partial hospitalization services include day, evening, night, and weekend treatment programs that employ an integrated, comprehensive, and complementary schedule of recognized treatment or therapeutic activities.

(a) Acute level partial hospitalization is provided by programs which:

(i) are operated by a hospital as described in 50-5-101, MCA, and are collocated with that hospital such that in an emergency a patient of the acute partial hospitalization program can be transported to the hospital′s inpatient psychiatric unit within 15 minutes;

(ii) serve primarily individuals being discharged from inpatient psychiatric treatment or inpatient psychiatric residential treatment; and

(iii) provide psychotherapy services consisting of at least individual, family, and group sessions at a frequency designed to stabilize patients sufficiently to allow discharge to a less intensive level of care at the earliest appropriate opportunity, on average, after 15 or fewer treatment days.

(b) Acute level partial hospitalization is reimbursed according to ARM 37.86.3022.

(c) Subacute level partial (SAP) hospitalization is provided by programs which:

(i) operate under the license of a general hospital with a distinct psychiatric unit or an inpatient psychiatric hospital for individuals under 21;

(ii) operate a self-contained facility and offer integrated mental health services appropriate to the individual′s needs as identified in an individualized treatment plan;

(iii) provide psychotherapy services consisting of at least three group sessions per week and five individual and/or family sessions per month;

(iv) encourage and support parent and family involvement;

(v) provide services in a supervised environment by a well-integrated, multidisciplinary team of professionals which includes program therapists, behavioral specialists, teachers, and ancillary staff;

(A) a program therapist must be a licensed mental health professional who is site-based;

(B) a program therapist must have an active caseload that does not exceed ten program clients;

(C) a behavioral specialist must be site-based and have a bachelor′s degree in a behavioral science field or commensurate experience working with children with serious emotional disturbance. There must be one behavioral specialist for each five youth in the SAP program; and

(D) all staff responsible for implementing the treatment plan must have a minimum of 24 hours orientation training and 12 additional hours of continuing education each year relating to serious emotional disturbance in children and its treatment. Training must include specific instruction on recognizing the effects of medication.

(vi) provide education services through one of the following:

(A) full collaboration with a school district;

(B) certified education staff within the program; or

(C) interagency agreements with education agencies.

(vii) provide crisis intervention and management, including response outside of the program setting;

(viii) provide psychiatric evaluation, consultation, and medication management on a regular basis. Psychiatric consultation to the program treatment staff is provided at least twice each month and includes at least one face-to-face evaluation with each youth each month;

(ix) serve children or youth with a serious emotional disturbance being discharged from inpatient psychiatric treatment or residential treatment or who would be admitted to such treatment in the absence of partial hospitalization; and

(x) are designed to stabilize patients sufficiently to allow discharge to a less intensive level of care, on average, after 60 or fewer treatment days.

(d) Subacute level partial hospitalization is reimbursed at the rate specified in the department′s Medicaid Mental Health Fee Schedule.

(3) For recipients determined Medicaid eligible by the department as of the time of admission to the partial hospitalization program, the Certificate of Need required under (1) must be:

(a) completed, signed and dated prior to, but no more than 30 days before, admission; and

(b) made by a team of health care professionals that has competence in diagnosis and treatment of mental illness and that has knowledge of the recipient's situation, including the recipient's psychiatric condition. No more than one member of the team of health care professionals may be professionally or financially associated with a partial hospitalization program. The team must include:

(i) a physician that has competence in diagnosis and treatment of mental illness, preferably in psychiatry;

(ii) a licensed mental health professional; and

(iii) an intensive case manager employed by a mental health center or other individual knowledgeable about local mental health services as designated by the department.

(4) For recipients who are being transferred from a hospital's acute inpatient program to the same facility's partial hospitalization program, the certificate of need required under (1) may be completed by a facility based team of health care professionals:

(a) that has competence in diagnosis and treatment of mental illness and that has knowledge of the recipient's psychiatric condition;

(b) that includes a physician that has competence in diagnosis and treatment of mental illness, preferably in psychiatry, and a licensed mental health professional; and

(c) the Certificate of Need must also be signed by an intensive case manager employed by a mental health center or other individual knowledgeable about local mental health services as designated by the department.

(5) For recipients determined Medicaid eligible by the department after admission to or discharge from the facility, the Certificate of Need required under (1) is waived. A retrospective review to determine the medical necessity of the admission to the program and the treatment provided will be completed by the department or its designee at the request of the department, a provider, the individual, or the individual's parent or guardian. Request for retrospective review must be:

(a) received within 14 days after the eligibility determination for recipients determined eligible following admission, but before discharge from the partial hospitalization program; or

(b) received within 90 days after the eligibility determination for recipients determined eligible after discharge from the partial hospitalization program.

(6) All Certificates of Need required under (1) must actually and personally be signed by each team member, except that signature stamps may be used if the team member actually and personally initials the document over the signature stamp.

(7) Prior authorization is not a guarantee of payment as Medicaid rules and regulations, client eligibility, or additional medical information on retrospective review may cause the department to refuse payment.