BH Community Crisis Stabilization (CCS) Form

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Community Crisis Stabilization (CCS) – Behavioral Health Policy
Updated Revision Effective: May 1, 2024 Policy Number:

UM350POL

Approval Date: 2/27/2024

Line(s) of Business: Commercial
Medicare Advantage
Medicaid (BeHealthy)

Description

Community Crisis Stabilization (CCS) is a less restrictive alternative to inpatient hospitalization for people in need of short-term, overnight crisis care. The programs offer services including individual, group, and family therapy; medication management; crisis intervention; and future crisis prevention planning.

 Line of Business

Commercial: No prior authorization required. Concurrent medical necessity review will be performed.
Refer to criteria under Policy section in this medical policy.

Medicaid – BeHealthy:
Medical necessity review is performed by the Massachusetts Behavioral Health Partnership (MBHP).

Medicare:
This policy does not apply.

Policy

Commercial Criteria for Concurrent review and ongoing approval of services:

A. Member must have the need for a 24-hour, 7-day a week facility staffed by 24 hour awake staff in a
staff-secure (unlocked) treatment setting and be appropriate for this level of treatment in an unlocked facility

B. Member requires short-term crisis stabilization and therapeutic services to include but not limited to psychiatric and pharmacological assessment.

C. Member requires continuous monitoring to provide an ongoing assessment of risk of harm to self and/or others.

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D. Member’s symptoms require a time-limited period, generally 1-14 days for stabilization and successful transitioning back to the community.

II. What is Not Covered:

A. Treatment of the effect of substance use in the absence of a DSM-5 mental health diagnosis

B. Treatment of antisocial behavior in the absence of an active DSM-5 diagnosis

C. Treatments of symptoms or behaviors are due to a condition that cannot be impacted in a short- term treatment setting.

Coding Guidance

Prior Authorization not required per DOI mandate. Concurrent review for ongoing services required.
Please refer to the behavioral health fee schedule for applicable codes

Note: CPT/HCPCS codes are included for informational purposes and may not be all inclusive. Inclusion or exclusion of a CPT/HCPCS code(s) does not signify or imply that the service described by the code is a covered or non-covered health service. Benefit coverage for health services is determined by the member’s specific benefit plan document and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee of payment. Other policies and coverage determination guidelines may apply.

References

Division of Insurance (2023, January 4). Bulletin 2023-07; Coverage for Certain Behavioral Health Acute Treatment; Issued 1/4/2023.

https://www.mass.gov/doc/bulletin-2023-07-coverage-for-certain-behavioral-health-acute-treatment- issued-january-4-2023/download

Saxon V, Mukherjee D, Thomas D. J. (2018) Behavioral Health Crisis Stabilization Centers: A New Normal. Ment Health Clin Psychol 2(3): 23-26.

Substance Abuse and Mental Health Services Administration (SAMHSA). (2020). National Guidelines for Behavioral Health Crisis Care, Best Practice Toolkit. www.samhsa.gov

Policy Implementation

Approved by the Medical and Pharmacy Policy Committee

Kate McIntosh MD MBA

Chief Medical Officer

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Saad Usmani MD MBA

Medical Director

Date Update 12/16/2009 Initial Policy Date 12/2023 Transferred to new template with no changes to criteria.
1/2024 Line of Business section added 2/2024 Changes to policy language without substantive changes to coverage for clarity

Medical Criteria Disclaimer

Property of Health New England. All rights reserved. The treating physician or primary care provider must submit to Health New England the clinical evidence that the patient meets the criteria for the treatment, testing or surgical procedure. Without this documentation and information, Health New England will not be able to properly review the request for prior authorization. The clinical review criteria reflect how Health New England determines whether certain services or supplies are medically necessary. Health New England established the clinical review criteria based upon a review of currently available clinical information (including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the technology, evidence-based guidelines of public health and health research agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas, and other relevant factors).
Health New England expressly reserves the right to revise these conclusions as clinical information changes, and welcomes further relevant information. Each benefit program defines which services are covered. The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered and/or paid for by Health New England, as some programs exclude coverage for services or supplies that Health New England considers medically necessary. If there is a discrepancy between this guideline and a member's benefits program, the benefits program will govern. In addition, coverage may be mandated by applicable legal requirements of a state, the Federal Government or the Centers for Medicare & Medicaid Services (CMS) for Medicare and Medicaid members. All coding and web site links are accurate at time of publication. Health New England has adopted the herein policy in providing management, administrative and other services to its Health Plan.