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Psychiatric Residential Treatment Facility (PRTF)

Posted: 07-27-2018

  • Overview
  • Eligible Recipients
  • Eligible Providers
  • Provider Responsibilities
  • Authorization Requirements
  • Covered Services
  • Services Outside the Per Diem (Arranged and Concurrent)
  • Leave Days
  • Billing
  • Legal References
  • Overview

    Psychiatric residential treatment facilities (PRTF) provide active treatment to children and youth under age 21 with complex mental health conditions. This is an inpatient level of care provided in a residential facility rather than a hospital. PRTFs deliver services under the direction of a physician, seven days per week, to residents and their families, which may include individual, family and group therapy. Children and youth under age 21 are eligible based on medical necessity, as determined by the state's medical review agent.

    A licensed mental health professional from the community or an acute care setting, along with the parent or legal guardian, may make a referral to a PRTF. Other members of an individual’s treatment team, such as case managers and other service providers, may have a role in facilitating the referral and providing information to support the referral. 

    Eligible Recipients

    Recipients must meet the following criteria to be eligible for admission to a PRTF:

  • • Under the age of 21 at the time of admission. Services may continue until the individual meets criteria for discharge or reaches 22 years of age, whichever occurs first.
  • • Referred by an enrolled MHCP provider qualified as a licensed mental health professional (as defined in MN).
  • • Have had a MCHP defined diagnostic assessment completed within 180 days of referral to the state medical review agent (MRA).
  • • Meet medical necessity to be admitted to a PRTF as determined by the state’s Medical Review Agent (See Inpatient Hospital Authorization section). For individuals with coverage other than MA fee-for-service, the referring licensed mental health professional coordinates with the PRTF and follows any authorization requirements of the individual’s health plan or payer.
  • • Have a mental health diagnosis as defined in the most recent edition of the Diagnostic and Statistical Manual for Mental Disorders, as well as clinical evidence of severe aggression, or a finding that the individual is a risk to self or others. 
  • • Have a functional impairment and a history of difficulty functioning safely and successfully in the community, school, home or job; an inability to adequately care for one's physical needs; or caregivers, guardians or family members are unable to safely fulfill the individual's needs. 
  • • Require psychiatric residential treatment to improve the individual’s condition or prevent further regression. 
  • • Other community-based mental health services have been exhausted or cannot provide the level of care needed.
  • Eligible Providers

    All PRTF providers must be selected through the request for proposals (RFP) process and be enrolled with Minnesota Health Care Programs (MHCP) to be eligible for reimbursement.

    Other requirements include:

  • Certification by the Minnesota Department of Health as a PRTF and meet licensing requirements for supervised living facilities (SLF)
  • • Licensed by the Department of Human Services
  • • Accredited by the Joint Commission (JCAHO), the Commission on Accreditation of Rehabilitation Facilities (CARF), or the Council on Accreditation of Services for Families and Children (COA)
  • Legislation in 2015 directed the state to enroll up to 150 beds at up to six sites statewide. 

    Provider Responsibilities

    Active treatment is provided seven days per week and may include individual, family or group therapy as determined by the individual plan of care. The individual plan of care is developed by the PRTF interdisciplinary treatment team following completion of a diagnostic evaluation. The individual plan of care must include an integrated program of therapies, activities and experiences designed to meet treatment goals. PRTF services include all of the following:

  • • Individual therapy provided a minimum of twice per week
  • • Family engagement activities provided a minimum of once per week
  • • Consultation with other professionals, including case managers, primary care professionals, community-based mental health providers, school staff or other support planners
  • • Coordination of educational services between local and resident school districts and the facility
  • • 24-hour nursing services
  • • Direct care and supervision, supportive services for daily living and safety, and positive behavior management
  • The purpose of treatment in a PRTF is to provide an inpatient level of care to improve an individual’s condition to the point where inpatient care is no longer necessary. Comprehensive discharge planning is essential for individuals to successfully transition to home, school and community as soon as possible. Discharge planning begins at the time of admission and requires coordination with the individuals, their families and community-based service providers. The individual plan of care must include discharge plans and coordination of services to ensure continuity of care with the beneficiary's family, school and community upon discharge.

    Admissions Guidelines

    Follow these admission guidelines:

  • • Admission and the first 60 days of treatment are authorized with the Inpatient Hospital Authorization (IHA) form (DHS-4676) (PDF) and providers must resubmit it after the initial 60 days and then every 30 days thereafter for the duration of treatment.
  • • If a recipient’s eligibility changes, and the recipient becomes eligible for Medical Assistance (MA) while admitted to the facility, the treatment team completes the certification of need and submits it with the plan of care to the DHS medical review agent (MRA). It will cover any period before application for which claims are made.
  • • Certification of need for care: A physician, physician assistant or nurse practitioner, acting within the scope of practice as defined by state law and under the supervision of a physician, must verify a recipient's need for continued placement at an inpatient hospital level of care. The initial certification consists of the admitting physician’s written order and plan of care documented in the medical record.
  • • Original payer will honor the prior authorization through the first of the next month, whether starting on fee-for-service (FFS) or managed care.
  • • If a recipient becomes MA FFS eligible, or changes from managed care to FFS while admitted to the PRTF, the treatment team at the facility completes the certification of need for services. Changes from managed care or other payers to FFS requires review by the DHS MRA. 
  • • PRTF providers are responsible for developing internal policies and procedures for determining if recipients requesting emergency admission meet the required medical necessity of a PRTF in the event of emergency admissions.
  • • MHCP is not liable for claims submitted for recipients determined to not meet medical necessity by the DHS MRA (this includes those recipients admitted on an emergency basis).
  • • Information about general appeals procedures are described by the DHS Appeals Division.
  • • A physician’s signature is required on the plan of care for initial admissions and continued stay reviews to satisfy IHA need for care certification or recertification requirements.
  • Authorization Requirements

    Inpatient Hospital Authorization Process

    1. Requesting Provider Responsibilities
    Providers must submit all requests for admissions through the medical review agent (MRA) electronic portal or fax using the Eligibility for Admission Form (DHS-7696) (PDF). Find contact information and assistance with accessing the MRA’s electronic portal on the DHS authorization website.

    The requesting licensed mental health professional making the referral must submit the following to the MRA:

  • • Eligibility for Admission form (DHS-7696)
  • • Most recent diagnostic assessment (DA) (completed within last 180 days).
  • • The DA must include functional assessments and use of standardized instruments such as CASII, SDQ, or LOCUS (for individuals over 18 years old) as well as substance abuse screens.
  • • The MRA will deny referrals submitted with diagnostic assessments dated beyond 180 days to the provider without further review.
  • The MRA may request additional documentation to establish medical necessity. Supporting documentation may include:

  • • Current or previous treatment plans for inpatient and outpatient treatment
  • • Discharge summaries from previous inpatient and outpatient treatment
  • • Other recent evaluations (e.g., psychological, neurological, occupational therapy, chemical dependency, etc.)
  • • Special educational records (most recent IEP, behavior intervention plan and educational testing)
  • • Other relevant school records (academic or grade reports, discipline or behavioral records) that provide examples of functional impairment in the school setting
  • • Records related to involvement in other systems of care (e.g., juvenile justice, child welfare, disability services) that provide examples of functional impairment in home and community
  • • Relevant medical, dental and vision records
  • The MRA will review the Eligibility for Admission form and supporting documents within five business days to determine whether the referral is approved, denied or pended. The MRA utilizes the InterQual Criteria - PRT subset to determine medical necessity.

    If the state MRA identifies the request as being incomplete during the initial screening, the MRA will pend the request for 20 business days to allow the requesting provider to submit the necessary information.

    The state’s MRA will create the necessary authorization (IHA) to show that a request for admission to a PRTF has been submitted. Authorizations are valid for 30 days upon approval. Recipients not admitted within the 30 day window must resubmit a new Eligibility for Admission form. If an admission date is planned within the 30 day timeframe, yet the admission date will take place after 30 days from the date of referral, the requesting mental health professional or PRTF must contact the MRA. After 30 days, the MRA will deny the claim and notify the referring mental health professional and recipient.

    Admission to a PRTF is coordinated with the facility based on bed availability and population served.

    The PRTF must continue authorization procedures following referral and upon accepting admission of the recipient.

    2. PRTF Responsibilities
    The PRTF is responsible for the following:

  • • Once the PRTF accepts admission of the recipient, it must request authorization by submitting a completed Inpatient Hospital Authorization (IHA) Form (DHS-4695) (PDF) and all required documentation supporting the medical necessity of PRTF services
  • • Upon admission, the treatment team and supervising physician verifies the certification of need for treatment in a PRTF
  • Initial authorizations are valid for 60 days of treatment in the PRTF. The MRA must review the plan of care every 30 days to determine continued medical necessity, and to approve an additional 30 days of treatment.

    Plan of Care (PoC)
    The PRTF must submit the recipient’s Individual Plan of Care and Authorization Form (DHS-7666-ENG) (PDF) no later than 14 days after admission. The initial plan of care should include a tentative discharge plan, a request for anticipated dates beyond the initial 60 days, if feasible, and an updated IHA (DHS-4695-ENG) (PDF), if applicable.

    Inpatient psychiatric services must involve “active treatment,” which means implementation of a professionally developed and supervised individual plan of care. The plan of care (PoC) must meet the following criteria:

  • • Must be based on a diagnostic evaluation that includes examination of the medical, psychological, social, behavioral and developmental aspects of the recipient’s situation and reflects the need for inpatient psychiatric care.
  • • Must include an integrated program of therapies, activities and experiences designed to meet treatment goals.
  • • May include other services that are provided under arrangement by licensed professionals who are not part of the treatment team (see Arranged Services section).
  • • Must include discharge plans and coordination of services to ensure continuity of care with the recipient’s family, school and community upon discharge.
  • Concurrent services are arranged services delivered by a community provider while the individual resides in the PRTF, or while the recipient is absent from the PRTF on a therapeutic leave. These services support continuity of care and successful discharge from the facility (see Concurrent Services section).

    If the PRTF does not submit the PoC within the required 14 days, there is no guarantee the MRA will review and authorize the PoC prior to the days requested for authorization. If the PRTF provides services without authorization, there is no guarantee of payment. MHCP will not pay claims for services rendered by a PRTF if a PoC has not been submitted, reviewed and authorized.

    Continued Stay Authorization Requirements
    The MRA must review the plan of care every 30 days to determine continued medical necessity for treatment and to approve an additional 30 days of treatment. This includes whether the recipient continues to meet criteria for PRTF services, and is making progress towards treatment goals and discharge. The following is required for authorization:

  • • The PRTF must submit an updated PoC prior to the 30th day of the last authorized date of service
  • • The PRTF must submit an updated IHA (DHS-4695) (PDF) anytime there are changes made to a PoC
  • • The PRTF must submit an updated PoC when the provider does any of the following:
  • • Requests additional days beyond the initial 30 days of treatment
  • • Adds or changes arranged services to the PoC that require authorization
  • • Adds or changes concurrent services to the PoC as part of the discharge plan
  • • Adds or changes therapeutic leave days
  • Changes in Insurance Coverage to MA Fee-for-Service
    When a recipient becomes eligible for MA fee-for-service while admitted to a PRTF, an updated PoC form is required to document this change. DHS is not obligated to honor a previous insurance inpatient authorization. The PRTF is responsible to submit necessary documentation to the MRA to obtain new authorization for treatment.

    The PRTF must submit the plan of care authorization request within 14 days of the effective date of change in coverage.

    The PRTF must also provide the following to the MRA:

  • • Verification of the original authorization by the original payer (if any)
  • • Current DA and DA at time of admission
  • • Current ITP and ITP at time of admission
  • • Current risk management assessment and risk assessment at time of admission
  • Authorization requests for Medicaid secondary coverage and third party liability (TPL) require additional documentation. Instructions are provided on the MCHP Authorization website.

    Emergency Medical Assistance (EMA) provides coverage for eligible recipients in a PRTF when the recipient has been determined to have an emergency medical condition. This requires an approved

    EMA Care Plan Certification (CPC) Request (DHS-3642) (PDF).

    For recipients covered under EMA, the provider must complete and submit an EMA CPC Request (DHS-3642) (PDF) along with supporting clinical information to the EMA medical review agent as detailed in the EMA Section of the MHCP Provider Manual. Outpatient medications also require a separate authorization under EMA. EMA does not provide coverage for early and periodic screening, diagnosis and treatment services (EPSDT) in conjunction with care in a PRTF.

    Changes in Primary Diagnosis
    The PRTF must submit an updated PoC to the MRA when the provider changes or updates a primary diagnosis.

    PRTF Covered Services

    The PRTF non-leave day per diem rate requires PRTF providers ensure the following services are delivered and available to recipients on a daily basis:

  • • Individual, family and group therapy
  • • Additional services may be arranged by the facility and included in the PoC to meet individual needs of the recipient. Arranged services may include occupational therapy, speech therapy, physical therapy or other necessary services not included as part of active treatment required by the PRTF.
  • Concurrent services included in the PoC for the purpose of continuity of care and discharge planning may be billed directly by the independently licensed organization.

    All PRTFs will be paid the same per diem rate regardless of the level of care provided to recipients.

    Services Outside the Per Diem (Arranged and Concurrent Services)

    The individual PoC may include other services that are provided under arrangement by licensed professionals who are not part of the treatment team. These arranged services may be delivered at the facility or in the community, and are billed by the licensed professional. These services must be identified in the individual plan of care. The following apply to arranged services:

  • • Reimbursement rates may be found on the Service Rates Information page
  • • The medical review agent must complete review of the PRTF authorization request, including plan of care, IHA and medical necessity for arranged services within five business days
  • Concurrent services are arranged services delivered by a community provider while the individual resides in the PRTF, or while the recipient is absent from the PRTF on a therapeutic leave (see the PRTF concurrent services chart).

    The following apply to concurrent services:

  • • These services support continuity of care and successful discharge from the facility
  • • The individual plan of care must identify these services and coordination with community providers
  • • Other arranged services may include dental care, acute medical exams, vision or other health care services not related to the condition for which the recipient was admitted to the PRTF
  • • The PRTF must include in the individual plan of care that it will arrange for such services when medically necessary
  • Leave Days

    A leave day means any calendar day during which the recipient leaves the facility and is absent overnight, and all subsequent, consecutive calendar days. An overnight absence from the facility of less than 23 hours does not constitute a leave day. Nevertheless, if the recipient is absent from the facility to participate in active programming of the facility under the personal direction and observation of facility staff, the day is not considered a leave day regardless of the number of hours of the recipient’s absences. For the purposes of this definition, “calendar day” means the 24-hour period ending at midnight.

    PRTF recipients are allowed two types of leave days:

    Therapeutic leave days are allowed to facilitate recipient reintegration into the community and ensure supports are in place to maintain long-term recovery.

  • • Therapeutic leave days must be included in the PoC with a corresponding IHA for authorization.
  • • Therapeutic leave days may not exceed three consecutive days. If additional days are needed, PRTF must add to PoC, complete and submit the Extended Leave Days Request Form (DHS-7695) for approval to the MRA.
  • • Concurrent services may be delivered to PRTF recipients on therapeutic leave days (required authorization needed as applicable).
  • • Therapeutic leave days are reimbursed at 75 percent of the regular PRTF per diem rate.
  • Hospital leave days are allowed in the event a PRTF recipient’s health needs require hospitalization.

  • • Hospital leave days may or may not be included on the PoC depending on circumstances.
  • • Hospital leave days are limited to seven consecutive days for each separate and distinct episode. If more than seven consecutive days are clinically necessary, PRTFs must complete and submit the Extended Leave Days Request Form (DHS-7695) for approval to the MRA.
  • • Hospital leave days are reimbursed at 50 percent of the regular PRTF per diem rate.
  • Billing

    Description of procedure code and limitations

    Service Description

    Units

    Revenue Code

    Claim Format

    Type of Bill

    Limitations

    All-inclusive room and board

    1 day

    0101

    837I
    Institutional claim

    086X

    Hospital leave days

    1 day

    0180

    837I
    Institutional claim

    086X

    A hospital leave day will be a day when a recipient requires admission to a hospital for medical or acute psychiatric care and is temporarily absent from the psychiatric residential treatment facility. Hospital leave days may not exceed seven consecutive days without prior authorization. 

    Therapeutic leave days

    1 day

    0183

    837I
    Institutional claim

    086X

    A therapeutic leave day to home will be to prepare for discharge and reintegration and will be included in the individual plan of care. A therapeutic leave visit may not exceed three days per visit without prior authorization.

  • • Bill all PRTF claims on a 837I claim type
  • • Bill for leave days (therapeutic and hospital) using the occurrence span code 74 (non-level of care absence days), Value Code 80.
  • Services Billed Outside the Per Diem and Limitations

    Payment for services outside the per diem may be limited, and these services may be subject to prior authorization by the state's medical review agent (MRA).

    Arranged and concurrent services are billed on a professional claim in accordance with the corresponding MHCP billing policy and must include the following:

  • • Bill professional services arranged by the facility and provided outside the contracted per diem on an 837P (Professional Claim)
  • • For arranged services, the provider should use POS (Place of Service) code 56 on claims
  • • For concurrent services, the provider should use the POS code typically used when submitting claims for any recipient of care
  • • Concurrent services will be billed by the licensed provider on an 837P (Professional Claim)
  • Services Billed Outside the Per Diem

    Service

    Service included in PRTF per diem?

    Billable outside the per diem as an arranged service?

    Billable outside the per diem as a concurrent service?

    Notes and specifications

    Access Services

    Yes

    No

    Yes

    *See below

    ACT

    No

    No

    Yes

    One ACT encounter billable per 30 day period.

    See Minnesota statutes 256.0941, Subd. 3 paragraph (d)

    *See below

    AMH-TCM

    No

    No

    Yes

    One TCM encounter billable per 30 day period.

    *See below

    ARMHS

    No

    No

    Yes

    Billable for ages 18 and older.

    Authorization would need to be obtained for transition to community living, a service within ARMHS that has its own billing code.

    *See below

    CCBHC

    No

    No

    Yes

    Billable for ages 21 and younger.

    See limitations for psychotherapy services.

    *See below

    Clinical Care Consultation-Child (Face to Face)

    No

    No

    Yes

    Calendar year threshold, 15 hours.

    *See below

    CMH-TCM

    No

    Yes

    Yes

    Up to six months while admitted to PRTF.

    *See below

    CTSS

    No

    No

    Yes

    Billable for ages 21 and younger.

    MN Statutes 256B.0943, Subd. 13. Exception to excluded services. Notwithstanding subdivision 12, up to 15 hours of children's therapeutic services and supports provided within a six-month period for the purposes of discharge planning.

    These 15 hours may be subject to prior authorization and will not count towards the 200 threshold hours.

    *See below

    Crisis Response Services (Adult and Child)

    No

    No

    Yes

    Mobile crisis assessment and intervention for adult or child.

    Community intervention for adult.

    On therapeutic leave days only.

    *See below

    Day Treatment

    No

    No

    No

    DBT

    Maybe

    No

    Yes

    18 or older.

    *See below

    EIDBI

    No

    No

    Yes

    With the following procedures and limitations:

  • • Prior to admission to the PRTF, determine whether to continue EIDBI services (e.g., family training and counseling) while person is receiving treatment in PRTF or following PRTF. The qualified supervising professional (QSP) must be included at the meeting to make this recommendation.
  • • No direct EIDBI treatment services (i.e., individual or group intervention) would be provided in the PRTF. The EIDBI SA should be ended on the date prior to the date the person is admitted to the PRTF for the services of EIDBI Intervention, individual or group.
  • Allowable services:

  • • CMDE if one year since last CMDE or if significant change in status, to determine EIDBI services upon discharge
  • • ITP progress monitoring
  • • Coordinated care conference
  • • Family caregiver training
  • • Travel – allowed for family caregiver training and counseling
  • Documentation that needs to be updated and submitted to MRA:

  • • Update to ITP to include: progress monitoring data update and summary of monthly coordinated care conference including PRTF facility, parent and EIDBI team members. The QSP is required, the Level I and II are optional participants. Determine if other service providers are necessary (e.g., physician, APRN, speech, OT, etc.).
  • • Documentation must support the medical necessity criteria for both EIDBI and PRTF services. The review agent may request additional documentation if necessary to make a determination. All services must be coordinated and documented.
  • *See below

    Explanation of Findings (MHCP)

    Yes

    Yes

    Yes

    *See below

    Health and Behavioral Assessment

    Yes

    Yes

    Yes

    *See below

    Inpatient Hospitalization

    No

    No

    Yes

    MN Statutes 256B.0941, Subdivision 4, paragraph (c), a hospital leave day shall be a day for which a recipient has been admitted to a hospital for medical or acute psychiatric care and is temporarily absent from the psychiatric residential treatment facility. The state shall reimburse 50 percent of the per diem rate for a reserve bed day while the recipient is receiving medical or psychiatric care in a hospital.

    Hospital leave days may not exceed seven consecutive days without prior authorization.

    *See below

    Interpreter Services

    Yes

    No

    Yes

    *See below

    Family Peer Specialists

    N/A

    N/A

    Yes

    PRTFs are not required to hire (family) peer specialists, yet could arrange for that service through a community based agency. PRTFs may elect to hire (family) peer specialists and include that in the per diem. (family) Peer specialist services may also be provided as a concurrent service by a community based agency in the child’s community of residence.

    *See below

    Family Psycho-education

    Yes

    No

    Yes

    *See below

    MH-TCM

    No

    No

    Yes

    1 unit per month

    For Indian Health Service/638 and FQHC: Per encounter (no more than 1x/day)

    *See below

    Physician Consultation

    No

    Yes

    Yes

    *See below

    Outpatient Psychotherapy

    No

    No

    Yes

    Subject to limitations and prior authorization:

  • • Therapy “without client present” (billing code 90846)
  • • Clinical care consultation
  • • Psychoeducation
  • • ITP must be updated to reflect this
  • *See below

    Partial hospitalization

    No

    No

    No

    Peer Specialists

    No

    Yes

    Yes

    PRTFs are not required to staff peer specialists, yet, could arrange for that service through a community based agency. PRTFs may elect to hire peer specialists and include that in the per diem. Peer specialist services may also be provided as a concurrent service by a community based agency in the child’s community of residence.

    *See below

    Psychiatric Consultations to Primary Care Providers

    No

    Yes

    Yes

    Face-to-face only

    *See below

    Psychological testing

    Not required

    Yes

    Yes

    Billable as arranged service: must be provided at PRTF.

    Billable as a concurrent service for the purpose of supporting continuity of care and successful discharge from the facility. Existing rules apply and enforced while recipient is admitted to a PRTF.

    *See below

    Rehab services

    (OT, PT, speech)

    No

    Yes

    Yes

    *See below

    Substance Use Disorder (SUD) Treatment

    Medication Assisted therapy – Methadone per diem

    Medication Assisted therapy – all other per diem

    No

    Yes

    Yes

    *See below

    Substance Use Disorder Treatment – Outpatient group or individual

    No

    No

    Yes

    *See below

    Waiver Services

    No

    No

    No

    County (of financial responsibility) must approve concurrent care.

    Waiver CM

    No

    No

    No

    See waiver services.

    Youth ACT

    No

    No

    Yes

    Limitations: one per month for the purpose of discharge planning (policy will be in MHCP manual).

    Billable for ages 16-20.

    [See Minnesota statutes 256.0941 Subd. 3 paragraph (d)]

    *See below

    For the purpose of supporting continuity of care and successful discharge from the facility.  Existing rules apply and enforced while recipient is admitted to a PRTF. Subject to limitations and prior authorization.

    Legal References

    Minnesota Statutes 256B.0941, Psychiatric Residential Treatment Facility for Persons Younger Than 21 Years of Age
    Minnesota Statutes 256B.0625, Subdivision 45a
    ,
    Psychiatric Residential Treatment Facility Services for Persons Younger than 21 Years of Age
    Code of Federal Regulations 42 CFR §441.151 through 441.182, Inpatient Psychiatric Services for Individuals Under Age 21
    Code of Federal Regulations 42 CFR §483.350 through 483.376, Conditions of Participation for use of Seclusion and Restraint

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    © 2018 Minnesota Department of Human Services Updated: 7/27/18 3:20 PM | Accessibility | Terms/Policy | Contact DHS | Top of Page | Updated: 7/27/18 3:20 PM