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Medicaid Partial Hospitalization Program and Intensive Outpatient Program Mental Health and Substance Use Disorder (SUD) Services Available

Date: 12/19/24

Superior HealthPlan’s provider network includes facilities who provide Partial Hospitalization Program (PHP) and Intensive Outpatient Program (IOP) as In Lieu of Services (ILOS).  ILOS may be provided as an  option to inpatient psychiatric hospitalization for Medicaid (STAR, STAR+PLUS, and STAR Health) adult members over 20 years of age. For Medicaid members under 21 years of age, PHP and IOP services may also available as a Texas Health Steps/Early Periodic Screening and Treatment (EPSDT) Medicaid benefit as an option to inpatient psychiatric hospitalization. Providers must educate members on the available options for receipt of medically necessary care, including the availability of these outpatient levels of care as an alternative to inpatient services. Prior authorization is required for both PHP and IOP, utilizing Superior’s existing prior authorization requirements.

Referral and Patient Choice of PHP or IOP as an alternative to an Inpatient Admission

PHP or IOP can be offered as an option to an inpatient admission when:

  • Outpatient PHP or IOP meets the clinical need and acuity of an identified patient.
  • Outpatient PHP or IOP is available to the patient in their community.
  • The patient or guardian agrees to the outpatient PHP or IOP as an option to inpatient psychiatric hospitalization.

All providers, including both providers who offer PHP or IOP programs within the provider’s facility, and those that do not can refer Superior members to an PHP or IOP program when an outpatient service is an appropriate and medically necessary option for the patient care. The patient must agree to the outpatient care as an alternative to an inpatient admission appropriate. For example, if a provider’s inpatient psychiatric facility does not offer PHP or IOP, a provider can still refer to an PHP or IOP in the community. Superior’s online provider directory includes a listing of contracted Superior providers available to deliver these services. To access this directory visit Superior's Find a Provider webpage.

When PHP or IOP is a viable alternative to an inpatient admission available to a Superior member/patient, the referring provider must discuss the outpatient PHP or IOP service as a medically necessary option in lieu of an inpatient admission with the patient and/or guardian. The provider must document the patient/LAR acceptance or refusal of PHP or IOP as an alternative to an inpatient psychiatric/SUD admission in the patient’s medical record.   

Prior Authorization Required

When PHP or IOP is the most appropriate setting for the medically necessary care for the patient, and the member agrees with this option for care, the provider must submit a prior authorization request to Superior to validate the medical necessity and appropriateness of the service.

In addition, when a member is discharged from an inpatient facility and an order for outpatient PHP or IOP services provided, it is possible those services may not need to be initiated or necessary immediately upon the member’s discharge for inpatient hospitalization. If PHP or IOP is needed immediately upon discharge, the processing of the prior authorization request will be processed according to the urgency of the PHP or IOP admission.

Superior does not require full psychiatric or medical histories for medical necessity determination for behavioral health or SUD PHP or IOP in lieu of services.  Superior requests a provider submit a member’s mental health medical record summary with a prior authorization request for these services.

The approval of PHP and IOP are based on the availability and medical necessity and appropriateness of the recommended service.  However, if a member/member’s family is unwilling or unable to support the members participation in an out-patient level of care for applicable behavioral health services, and inpatient services is the only available or viable option for the family/patient, the applicable service will be approved, if medically necessary.

PHP and IOP Billing

PHP services – This program offers the same behavioral health or substance use disorder (SUD) services that would be offered during an inpatient stay, with the key exception that the patient does not stay at the hospital overnight. The patient is present at the facility to receive these services each day. Revenue billing codes for PHP are included below:

  • 912 Behavioral health treatment services, partial hospitalization, less intensive
  • 913 Behavioral health treatment services, partial hospitalization, intensive

IOP services – A structured program that offers a milieu of outpatient therapy. This can vary based on the program, but typically includes individual and group therapy. Family therapy may occur as needed. Therapy sessions are provided by licensed clinicians. IOP patients attend 3-5 days a week and typically a minimum of 3 hours a day. Revenue billing codes for IOP are included below:

  • 905 Behavioral health treatment services, intensive outpatient psychiatric
  • 906 Behavioral health treatment services, intensive outpatient chemical dependency

If you have any questions related to these services or requirements, please contact Provider Services at 1-877-391-5921.