Psychiatric Residential Treatment Facilities (PRTF) will provide active treatment to children and youth under age 21 with complex mental health conditions. This is an inpatient level of care provided in a residential facility rather than a hospital. PRTFs deliver services under the direction of a physician, seven days per week, to residents and their families, which may include individual, family and group therapy. A resident’s plan of care may also include arranged services or specialty therapies, such as occupational therapy, physical therapy or speech therapy.
PRTF discharge planning begins at the time of admission and requires coordination with the individuals, their families and community-based service providers. Comprehensive discharge planning is essential for individuals to successfully transition to home, school and community as soon as possible.
Eligibility Criteria (to be used for initial and concurrent review)
To be eligible for PRTF, Minnesota Health Care Programs (MCHP) members must meet all of the following criteria:
Be under 21 at time of admission
Services may continue until individual meets discharge criteria or reaches 22 years of age, whichever occurs first
Has 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
Has functional impairment and a history of difficulty in functioning safely and successfully in the community, school, home, or job; an inability to adequately care for one's physical needs; or caregivers, guardians, or family members are unable to safely fulfill the individual's needs
Requires 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
Utilized and exhausted other community-based mental health services, or clinical evidence indicates that such services cannot provide the level of care needed
Was referred for treatment in a psychiatric residential treatment facility by a qualified mental health professional
A mental health professional making a referral shall submit documentation to the state's medical review agent containing all information necessary to determine medical necessity, including a standard diagnostic assessment completed within 180 days of the individual's admission. Documentation shall include evidence of family participation in the individual's treatment planning and signed consent for services.
A qualified mental health professional may make a referral to a PRTF. A qualified mental health professional must meet requirements outlined in MN Statutes, section 245.4871, subd. 27, clauses (1) to (6). Other members of an individual’s treatment team, such as case managers and other service providers, may have a role in facilitating the referral and providing information to support the referral. Please refer to the MHCP Manual for more detailed requirements and instructions for authorization and billing for PRTF services.
Licensed mental health providers referring Medicaid (fee-for service) recipients must do the following:
Submit DHS Form 7696, and all supporting documentation listed above, to the state’s medical review agent via KEPRO’s Atrezzo Portal (preferred) or fax.
A review determined to meet medical necessity will remain valid as long as the diagnostic assessment is current and there are no significant changes in symptoms and/or needs of the child/youth.
Coordinate with the PRTF facility regarding intake and admissions, and anticipated admission date.
For individuals with coverage other than Medicaid fee-for-service, the referring licensed mental health professional will coordinate referral and admission with the PRTF, and follow any authorization requirements of the individual’s health plan or payer.