Archived post, kept for historical context. The payer’s current requirements govern.
Your template for referring to PHP or other levels of care for behavioral health starts with the basic medical necessity criteria from insurance payers.
Medical necessity criteria for Partial Hospitalization Programs (PHP) in behavioral health vary by state, insurance payer, treatment facility and each patient’s needs. Medicare’s Benefit Policy Manual lists criteria for PHP care, and other payers publish their own. A referral letter can address the eight points below, a general outline to measure against the payer’s own policy:
- Diagnosis: The patient must have a diagnosable mental health condition that requires intensive treatment. Conditions include severe depression, bipolar disorder, schizophrenia, substance use disorders, eating disorders and other severe mental illnesses.
- Risk of Harm: The patient should present a risk of harm to themselves or others. This could manifest as suicidal ideation, self-harm, severe impairment in daily functioning, or violent tendencies.
- Symptom Severity: The severity of the patient’s symptoms should be such that they require more than outpatient care but do not require 24-hour inpatient hospitalization. Medicare’s manual describes PHP patients as needing structured, intensive treatment without 24-hour supervision, with an adequate support system outside the program.
- Functional Impairment: The patient’s mental health condition should significantly impair their ability to function in daily life, including but not limited to work, school, relationships, and self-care.
- Lack of Progress in Outpatient Care: The patient should have demonstrated a lack of progress or inadequate response to outpatient treatment or less intensive levels of care, such as individual therapy or outpatient group therapy.
- Medical Stability: The patient should be medically stable enough to participate in a day program without requiring constant medical supervision. Any medical conditions that need attention should not be so severe that they overshadow the need for mental health treatment.
- Support System: Ideally, the patient should have a support system or a safe, stable living environment to return to in the evenings, when they are not in the PHP.
- Treatment Plan: There should be a clear and comprehensive treatment plan in place that outlines the patient’s specific goals and objectives in the PHP, as well as a plan for transitioning to lower levels of care when appropriate.
Where a payer’s published criteria differ from the eight points above, the payer’s policy controls.
Sample referral letter to help with authorization approval:
[Your Name]
[Your Title]
[Your Clinic/Hospital Name]
[Address]
[City, State, ZIP Code]
[Phone Number]
[Email Address]
[Date: MM/DD/YYYY]
To Whom It May Concern,
I am writing this letter to provide a strong recommendation for [Patient’s Full Name], a valued patient under my care, to receive treatment at the Partial Hospitalization Program (PHP) level of care for mental health. I have had the privilege of overseeing [Patient’s Name]’s medical care for [duration of treatment relationship], and I believe that the PHP level of care is an appropriate and necessary step in their journey towards improved mental health and well-being.
[Patient’s Name] is a [age]-year-old [gender] who has been struggling with [brief description of the patient’s mental health condition or concerns, including any relevant diagnoses, such as depression, anxiety, bipolar disorder, etc.]. Despite our best efforts, [he/she/they] have experienced significant challenges in managing their symptoms, which have begun to impact [his/her/their] daily functioning, relationships, and overall quality of life.
After careful consideration and a thorough assessment, I firmly believe that the PHP level of care offers the intensive and comprehensive treatment that [Patient’s Name] requires at this stage. The structured environment, consistent therapeutic support, and access to a multidisciplinary team of mental health professionals provided by the PHP program will be instrumental in addressing [Patient’s Name]’s complex needs.
Specifically, I anticipate that the PHP program will provide the following benefits for [Patient’s Name]:
Structured Therapy: [Patient’s Name] will have the opportunity to engage in structured group and individual therapy sessions designed to address [his/her/their] specific mental health challenges.
Medication Management: The PHP program’s medical staff will closely monitor [Patient’s Name]’s medication regimen, ensuring that [he/she/they] receive the appropriate adjustments and support.
Psychoeducation: Psychoeducational sessions will give [Patient’s Name] insight and coping strategies that will help [him/her/them] manage [his/her/their] symptoms outside the program.
Peer Support: Time with peers who face similar struggles can reduce isolation and build a supportive environment.
Whole-Person Care: The PHP program will address [Patient’s Name]’s physical, emotional and psychological health.
I recommend [Patient’s Full Name] for admission to Partial Hospitalization for mental health. I am confident the program’s team and resources will provide the support to help [him/her/them] make progress in [his/her/their] recovery.
I can be reached at [phone number] or [email address] for additional information on [Patient’s Name]’s medical history and current condition. I am dedicated to collaborating closely with the PHP program to ensure the best possible outcomes for [Patient’s Name].
Thank you for your attention to this matter.
Sincerely,
[Your Signature]
[Your Printed Name]
[Your Title]
[Your License Number]
[Your Clinic/Hospital Name]
Have a stuck claim?
Put this into practice.
We work denials, appeals and underpayments for behavioral-health providers.