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December 2016 Texas Medicaid Provider Procedures Manual

Inpatient and Outpatient Hospital Services Handbook : 3 Inpatient Hospital (Medical/Surgical Acute Care Inpatient Facility) : 3.4 Services, Benefits, Limitations, and Prior Authorization - Inpatient Psychiatric Services : 3.4.5 Medicaid Clinical Criteria for Inpatient Psychiatric Care for Clients

The client must have a valid AXIS I, DSM diagnosis as the principle admitting diagnosis and outpatient therapy or partial hospitalization has been attempted and failed, or a psychiatrist has documented reasons why an inpatient level of care is required. The client’s Axis II diagnosis must also be included on the request for inpatient psychiatric treatment.
The client must meet at least one of the following criteria:
Recent self-mutilative behavior or active threats of same with likelihood of acting on the threat and an absence of appropriate supervision or structure to prevent self-mutilation (i.e., intentionally cutting or burning self).
Active hallucinations or delusions directing or likely to lead to serious self-harm or debilitating psychomotor agitation or intellectual disability resulting in a significant inability to care for self.
Significant inability to comply with prescribed medical health regimens due to concurrent Axis I psychiatric illness and such failure to comply is potentially hazardous to the life of the client. The medical (AXIS III) diagnosis must be treatable in a psychiatric setting.
The client is a danger to others. This behavior should be attributable to the client’s specific AXIS I or DSM diagnosis and can be adequately treated only in a hospital setting. This danger is demonstrated by one of the following:
Recent life-threatening action or active homicidal threats of same with a deadly plan and availability of means to accomplish the plan with likelihood of acting on the threat.
Recent serious assaultive or sadistic behavior or active threats of same with likelihood of acting on the threat and an absence of appropriate supervision or structure to prevent assaultive behavior.
The client exhibits acute onset of psychosis or severe thought disorganization, or there is significant clinical deterioration in the condition of someone with a chronic psychosis, rendering the client unmanageable and unable to cooperate in treatment, and the client is in need of assessment and treatment in a safe and therapeutic setting.
The client’s evaluation and treatment cannot be carried out safely or effectively in other settings due to severely disruptive behaviors and other behaviors which may also include physical, psychological, or sexual abuse.
The client is involved in the legal system, manifests psychiatric symptoms, and is ordered by court to undergo a comprehensive assessment in a hospital setting to clarify the diagnosis and treatment needs.
The proposed treatment or therapy requires 24-hour-a-day medical observation, supervision, and intervention and must include all of the following:
Active supervision by a psychiatrist with the appropriate credentials as determined by the Texas Medical Board (TMB) and with documented specialized training, supervised experience, and demonstrated competence in the care and treatment of children and adolescents. Treatment or therapy plans must be guided by the standards of treatment specified by the Texas Society of Child and Adolescent Psychiatry.
Provision of services which can reasonably be expected to improve the client’s condition or prevent further regression so that a lesser level of care can be implemented.
Proper treatment of the client’s psychiatric condition requires services on an inpatient basis under the direction of a psychiatrist and is being provided in the least restrictive environment available, and ambulatory care resources available in the community do not meet the client’s needs.

Texas Medicaid & Healthcare Partnership
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