Psychiatric Residential Treatment Facility (PRTF)

Revised: July 9, 2024

· Overview

· Eligible Providers

· Eligible Members

· Covered Services

· Noncovered Services

· Emergency Medical Assistance (EMA)

· Provider Responsibilities

· Eligibility, Initial, and Continued Stay Requirements

· Services Outside the Per Diem (Arranged and Concurrent)

· Leave Days

· Billing

· Legal References

Overview

Psychiatric Residential Treatment Facilities (PRTFs) provide active treatment at an inpatient level of care under the direction of a physician, seven days per week, to youth under age 21 with complex mental health needs and their families, based on medical necessity. Medical necessity is determined by the Arkansas Foundation for Medical Care (AFMC). PRTFs are not Institutions for Mental Disease (IMDs).

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 needed. PRTF level of care includes daily active treatment, which is achieved through a combination of family, group, and individual therapy, consultation and treatment planning with a comprehensive team of medical and behavioral health staff, and a highly structured living environment. Comprehensive discharge planning begins at the time of admission, to aid in a successful transition to home, school and community as soon as possible.

PRTFs are not considered foster care placements. Children or youth are admitted to a PRTF only after medical necessity is determined. Refer to the Adoption and Foster Care Analysis and Reporting System Social Service Information System Placement Guide (AFCARS) (DHDS-8119C) if you are a county or agency with placement authority for more information.

Eligible Providers

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.

You must meet all of the following requirements to enroll with MHCP as a PRTF provider:

· Certified by Minnesota Department of Health as a PRTF and meet requirements for Board and Lodging or supervised living facilities (SLF) licensure.

· Licensed by Minnesota Department of Human Services

· Accredited by one of the following:

· Joint Commission

· Commission on Accreditation of Rehabilitation Facilities

· Council on Accreditation of Services for Families and Children

Eligible Members

MHCP members must be on MA or MNCare and meet all the following criteria to be eligible for admission to a PRTF (initial and concurrent services):

· Be under 21 at time of admission.

· Services may continue until individual meets discharge criteria or reaches 22 years of age, whichever occurs first

· Have a mental health diagnosis as defined in the most recent edition of the Diagnostic and Statistical Manual for Mental Disorders (DSM), as well as clinical evidence of severe aggression, or a finding that the individual is a risk to self or others.

· Have functional impairment and a history of difficulty in functioning safely and successfully in the community, school, home or job.

· Have an inability to adequately care for one's physical needs; or have caregivers, guardians or family members who are unable to safely fulfill the individual's needs.

· Require psychiatric residential treatment under the direction of a physician to improve the individual's condition or prevent further regression so that services will no longer be needed.

· Have utilized and exhausted other community-based mental health services, or clinical evidence indicates that such services cannot provide the level of care needed.

· Have been referred for treatment in a PRTF facility by a qualified mental health professional.

Covered Services

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.

Noncovered Services

Nonauthorized PRTF services are not covered. This includes, but is not limited to:

· Services for members admitted on an emergency basis.

· Services provided at Institutions for Mental Disease (IMDs).

Emergency Medical Assistance (EMA)

EMA provides coverage for eligible members in a PRTF when the member has been determined to have an emergency medical condition.

Providers must complete and submit Emergency Medical Assistance - Care Plan Certification Request (DHS-3642) (PDF) along with supporting clinical information to the EMA medical review agent as detailed in the Emergency Medical Assistance section of the MHCP Provider Manual.

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.

Documentation

· Admission and the first 90 days of treatment are authorized with the Psychiatric Residential Treatment Facility (PRTF) Individual Plan of Care and Authorization (DHS-7666). Providers must submit DHS-7666 within 14 days of admission, then resubmit it after the initial 90 days and then every 90 days thereafter for the duration of treatment.

· 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 member'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.

· The individual plan of care is developed by the PRTF interdisciplinary treatment team, based on a current diagnostic assessment (DA) or DA equivalent. The individual plan of care must include an integrated program of therapies, activities and experiences designed to meet treatment goals.

· A physician’s signature is required on either the plan of care or treatment plan for admissions and continued stay reviews. Inpatient Hospital Authorization need for initial certification or recertification requirements.

· PRTF providers are responsible for developing internal policies and procedures for determining if members requesting emergency admission meet the required medical necessity of a PRTF in the event of emergency admissions.

Eligibility, Initial, and Continued Stay Requirements

Use the following two-step process to document PRTF eligibility, and for admission or subsequent authorization requests

Step 1: Referring Provider Responsibilities to obtain PRTF eligibility
The requesting licensed mental health professional making the referral must submit the following via encrypted email to Arkansas Foundation for Medical Care (AFMC) at mnprtf@afmc.org:

· Psychiatric Residential Treatment Facility (PRTF) Eligibility for Admission (DHS-7696) (PDF)

· Most recent DA (completed within last 180 days). As long as all the elements of a standard DA are met, a psychological or psychiatric evaluation completed by a licensed psychologist or medical doctor may be accepted.

· AFMC will not review referrals submitted with a DA or DA Equivalent information older than 180 days.

· Referral sources must establish a secure email account with AFMC prior to submitting any documentation. Email mnprtf@afmc.org to begin the process. Email dhs.prtf@state.mn.us with questions regarding forms or required documentation.

Clinical Review
AFMC will review the Eligibility for Admission form and supporting documents within three business days (Monday through Friday) to determine whether the referral is approved, denied, or pended.

AFMC 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 (for example, psychological, neurological, occupational therapy, chemical dependency or similar).

· 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 (for example, juvenile justice, child welfare, disability services) that provide examples of functional impairment in home and community.

· Relevant medical, dental, and vision records.

Incomplete requests may be pended up to 15 business days to allow the referring provider additional time to submit all necessary information.

AFMC will notify members and referring providers of eligibility. The referring provider must coordinate the member’s admission with PRTF provider.

The Eligibility for Admission is valid for 180 days upon approval, or as long as the diagnostic evaluation or diagnostic equivalent is current. Members not admitted within the 180-day window must have a new Eligibility for Admission form submitted. Admission to a PRTF is coordinated with the facility, and is based on bed availability and population served.

Step 2: PRTF Responsibilities for Admission and Continued Stay Authorization (Used for billing)
The PRTF provider must submit a completed Individual Plan of Care and Authorization Form (DHS-7666-ENG) (PDF) within 14 days of when the member is admitted. This initial plan of care should include a tentative discharge plan, and any additional dates beyond the initial 90 days of authorization.

If the PRTF does not submit the plan of care to AFMC within 14 days of the member’s admission, the authorization may not be approved.

Inpatient psychiatric services must involve “active treatment,” which means implementation of a professionally developed and supervised individual plan of care. The plan of care 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 member’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 (refer to Arranged Services section).

· Must include discharge plans and coordination of services to ensure continuity of care with the member’s family, school and community upon discharge.

Continued Stay Requirements for Authorization
AFMC will review the plan of care every 90 days to determine continued medical necessity and approve up to 90 additional days of treatment. This will determine if the member continues to meet criteria for PRTF services and is making progress towards treatment goals and discharge. The PRTF must submit an updated plan of care to AFMC at least 10 days before the end of the current authorization period, and include supporting clinical documents.

The PRTF must also submit an updated plan of care to AMFC within 14 days when any of the following occurs:

· Changes or updates a primary diagnosis.

· Changes or updates to insurance.

· Requests additional days beyond the initial authorized treatment days.

· Adds or changes arranged services to the plan of care that require authorization.

· Adds or changes concurrent services to the plan of care as part of the discharge plan.

· Adds or changes therapeutic leave days.

PRTF Discharge
When a member is discharged, the PRTF provider must submit an updated plan of care (DHS-7666) and discharge summary within 48 hours to mnprtf@afmc.org.

Services outside the Per Diem (Arranged and Concurrent Services)

Arranged Services – Professional services outside the per diem arranged by and provided at the facility by licensed professional. This must be included in the plan of care.

Concurrent Services – Limited services provided by another provider can be provided at the facility that supports continuity of care and successful discharge from a PRTF. Concurrent services may occur on, but are not limited to, therapeutic leave days.

Payment for services outside the per diem may be limited, and these services may be subject to prior authorization. Follow the billing and authorization requirements outlined on the corresponding MHCP manual page.

Reimbursement rates may be found on the Service rates information webpage.

PRTF Covered Concurrent Services

· Access Services

· Assertive Community Treatment (ACT) (Concurrent only) - One ACT encounter billable per 30-day period

· Adult Mental Health – Targeted Case Management - One TCM encounter billable per 30-day period

· Adult Rehabilitative Mental Health Services (ARMHS) - Billable for ages 18 and older. Authorization needs to be obtained for Transition to Community Living, a service within ARMHS that has its own billing code.

· Certified Community Behavioral Health Clinic (CCBHC)

· Children’s Mental Health Clinical Care Consultation

· Children’s Mental Health – Targeted Case Management

· Children’s Welfare Targeted Case Management

· Certified Family Peer Specialist

· Adult Crisis Response Services

· Children’s Mental Health Crisis Response Services

· Children’s Therapeutic Services and Supports (CTSS)

· Diagnostic Assessment

· Early Intensive Development and Behavioral Intervention (EIBDI)

· Explanation of Findings

· Health & Behavioral Assessment/ Intervention

· Inpatient Visits - Billable on hospital leave days

· Neuropsychological Services

· Physician Consultation, Evaluation and Management

· Family Psychoeducation

· Psychotherapy

· Psychiatric Consultations to Primary Care Providers

· Substance Use Disorder Services (SUD)

· Transportation Services - Billable when provided for services indicated on the treatment plan

Leave Days

Therapeutic leave days
If the member is not discharged from the facility, but goes home to prepare for discharge and reintegration, therapeutic leave days must be included in the plan of care with a corresponding PRTF authorization.

Therapeutic leave days may not exceed three consecutive days. If additional days are needed, the PRTF must add to the member’s plan of care, and submit a completed Psychiatric Residential Treatment Facility (PRTF) Extended Leave Request (DHS-7695) (PDF) to dhs.prtf@state.mn.us.

Concurrent services may be delivered to PRTF members on therapeutic leave days (required authorization needed as applicable). Therapeutic leave days are reimbursed at 75 percent of the provider per diem rate.

Hospital leave days
Hospital leave is used when a member is admitted to hospital for medical or acute psychiatric care and is temporarily absent from the PRTF. Hospital leave days may or may not be included on the Plan of care, 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 submit a completed Psychiatric Residential Treatment Facility (PRTF) Extended Leave Request (DHS-7695) (PDF) to dhs.prtf@state.mn.us for approval. Hospital leave days are reimbursed at 50 percent of the provider per diem rate.

Billing

MHCP requires providers to verify eligibility before you render services and submit claims. When verifying eligibility, also verify that the member’s living arrangement (LA) span in MMIS specifies code 62.

Use the MN–ITS 837I to bill PRTF. Include the following:

· The actual admission date

· The corresponding monthly authorization provided by AFMC. Use occurrence span code 74 for therapeutic and hospital level of care absence days.

· Use Value Code 80 for covered days.

Use the MN–ITS 837P to bill arranged and concurrent services.

Include place of service (POS) code 56 for arranged services delivered at the facility.

Include the POS code typically used when submitting claims for concurrent services delivered in the community.

Description of Revenue Codes and Limitations

Service description	Units	Revenue code	Claim format	Type of bill	Limitations
All-inclusive room and board	1 day	0101	837I Institutional claim	86X	Not applicable
Hospital leave days	1 day	0180	837I Institutional claim	86X	Hospital leave days may not exceed seven consecutive days without prior approval.
Therapeutic leave days	1 day	0183	837I Institutional claim	86X	A therapeutic leave visit may not exceed three days per visit without prior approval.
Arranged or concurrent services (outside per diem)	Not applicable	Not applicable	837P Professional claim	Not applicable	All services must be detailed in the individual plan of care.

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, title 42, sections 441.151 through 441.182, Inpatient Psychiatric Services for Individuals Under Age 21
Code of Federal Regulations, title 42, sections 483.350 through 483.376, Conditions of Participation for use of Seclusion and Restraint