OMHSAS Releases Intensive Behavioral Health Services Medical Necessity Criteria

Readers may recall that the state’s Office of Mental Health and Substance Abuse Services (OMHSAS) is transitioning from children’s Behavioral Health Rehabilitation Services to Intensive Behavioral Health Services (IBHS).  Regulations for IBHS went into effect on January 17, 2020 and behavioral health providers interested in offering IBHS to children, youth, and young adults until age 21 have until January 17, 2021 to become licensed providers. 

In mid-July, OMHSAS released Bulletin 20-05 outlining the medical necessity criteria that must be met for IBHS to be authorized by OMHSAS and the Medicaid Behavioral Health Managed Care plans.  IBHS is comprised of Individual, Group and ABA services.  All services require a written order by a qualified behavioral health professional and a comprehensive assessment. 

Individual services can include a Behavioral Consultant (BC), Mobile Therapist (MT) and/or a Behavioral Health Technician (BHT).  According to Attachment 1 of the Bulletin, the use of BC, MT and BHT are medically necessary when said services are reasonably expected to reduce or ameliorate the child’s, youth’s, or young adult’s identified therapeutic needs and increase the child’s, youth’s, or young adult’s coping strategies – or are necessary to support skill development to promote positive behaviors that will assist the child, youth, or young adult with achieving or maintaining maximum functional capacity.  Additionally, the behaviors cannot pose a risk to the safety of the child, youth, or young adult or others that cannot be managed while in the community and the individual does not require a more restrictive level of care, such as inpatient treatment or a psychiatric residential treatment facility.  Attachment 1 of the Bulletin goes on to describe the medical necessity criteria for continuation of Individual Services and criteria for discharge and service transition. 

Attachment 2 of the Bulletin defines the medical necessity criteria for Applied Behavioral Analysis (ABA) services.  Intensive Behavioral Health Services (IBHS) can be delivered through ABA services, which can be delivered through Behavior Analytic (BA), Behavior Consultation–ABA (BC-ABA), Assistant Behavior Consultation–ABA (Asst. BC-ABA) or Behavioral Health Technician–ABA (BHT-ABA) services.  (Detailed explanations about these services can be found here.)  The medical necessity criteria for the various ABA services are essentially the same as those for Individual Services.  Attachment 2 also defines the criteria for the continuation of ABA and for discharge and service transition. 

Attachment 3 of the OMHSAS Bulletin describes and defines the medical necessity criteria for Group Services with IBHS.  The criteria for Group Services mimic those for Individual and ABA services, focusing on amelioration of negative behaviors or symptomatology and increase in positive coping strategies and skill development which can be delivered safely in the home, school, and community.  As with the other two types of IBHS, Attachment 3 includes the medical necessity criteria for continuation of services, as well as discharge and service transition to a lesser or more intensive level of care. 

Comments and questions regarding OMHSAS Bulletin 20-05 should be directed to the Office of Mental Health and Substance Abuse Services, Bureau of Children’s Behavioral Health Services P.O. Box 2675, Harrisburg, PA 17105.  The General Office Number is 717-705-8289.  

Parents and others trying to locate a licensed IBHS provider can search the state’s provider directory by clicking on Intensive Behavioral Health Services in the Service Code section.  

Parents or guardians of children and youth who are denied Individual, ABA, or Group IBHS as not medically necessary can contact PHLP’s Helpline at 1-800-274-3258 for advice or representation with an appeal.