Privacy Issues in Mental Health and Substance Abuse Treatment: Information Sharing Between Providers and Managed Care Organizations: Final Report. Appendix G: American Psychiatric Association Minimum Necessary Guidelines for Third Party Payers for Psychiatric Treatment

01/17/2003

The following American Psychiatric Association position statement has been developed in response to the HHS final Privacy Rule's provision that health-care "providers" (health-care professionals and facilities) disclose only the "minimum necessary" information for a given purpose. The Final Rule clarifies that "providers" may make their own determination about what is the "minimum necessary" information for a specific purpose, and also invites "professional organizations, working with their members, to assess the effects of the standards and develop policies and procedures to come into compliance with them." (p. 82472) The Rule also states that this standard is "intended to reflect and be consistent with, not override, professional judgment and standards." (p 82544)

The following guidelines are based on the cumulative professional experience of APA members with respect to current practice and the necessity of privacy for effective psychiatric care. These guidelines are based on the principle that standards for "minimum necessary" disclosure of psychiatric information to third-party payers should not exceed standards generally accepted in other medical specialties.

These guidelines address the specific delimited set of information that is necessary to process a typical claim, and therefore constitutes the minimum necessary information that may be disclosed to third party payers under the HHS Privacy Rule.

This is not a policy position about how much/what information should be documented in the record about mental-health treatment and psychotherapy. Documentation guidelines, consistent with the HHS Privacy Rule, regarding general mental-health treatment records and psychotherapy notes will be addressed in a separate document. Material in psychotherapy notes, as defined in the HIPAA Privacy Rule, is not disclosed to third-party payers.

The purpose of this document is to specify the particular items of information that the APA believes fall within the "minimum necessary" criteria for routine processing of typical insurance claims for psychiatric treatment. Psychiatrists should also familiarize themselves with applicable state statutes, which may impose additional and/or different requirements with regard to the protection of confidentiality and privacy.

The APA's guidelines for "minimum necessary" are in three parts:

1. outpatient treatment that has been authorized for payment,

2. outpatient treatment requiring pre-authorization, and

3. inpatient treatment.

#1: Outpatient treatment that has been pre-authorized for payment (including sessions that do not require any pre-authorization by payer).

The first part of the "minimum necessary" guidelines for third-party payers, which follows below, concerns outpatient treatment that has been pre-authorized for payment or outpatient treatment that is not subject to pre-authorization.

Minimum necessary information:

The following information is deemed the "minimum necessary" information that is needed by, and may therefore be disclosed to, third party payers in order for them to process a routine claim for outpatient psychiatric services that are not subject to additional pre-authorization. The guideline is based on the current HCFA 1500 claim form (attached) and the protocol for disclosures to third party payers mandated in the Washington DC and New Jersey third-party mental-health privacy statutes (attached). These statutes place explicit limits on disclosure to payers of information related to mental health treatment. The restriction on disclosure to payers in these statutes has been endorsed by the U.S. Surgeon General in his Report on Mental Health (December 1999, Chapter 7).

Patient's name, address, date of birth, insurance information/ID number.

Patient's diagnosis by DSM or ICD code

Date(s), type and location of service

Procedure code - CPT code

Charges

Clinician's name, ID number (i.e. SSN or EIN, and/or clinician's provider number)

Clinician's address

If a payer cannot make a determination based on the above information, it may then request the provider to disclose additional information, limited to the following:

Patient's status (i.e. voluntary, involuntary,

Functional status (impairment described as none, mild, moderate or severe)

Level of distress (described as none, mild, moderate or severe)

Prognosis - the estimated minimum duration of the treatment for which the claim has been submitted.

#2: Outpatient treatment that requires authorization for payment.

The second part of the "minimum necessary" guidelines for third-party payers, which follows below, concerns outpatient treatment that requires authorization for payment of outpatient treatment. This includes prospective or retrospective reviews for this purpose.

Minimum necessary information:

The following information is deemed the "minimum necessary" information that is needed by, and may therefore be disclosed to, third party payers in order for them to authorize payment for outpatient psychiatric services. The guideline is based on the HCFA 1500 Claim Form, the Washington DC and NJ peer review laws, and page 1 of the APA Outpatient Treatment Report Form (12/98, attached). Consistent with the Rule's "minimum necessary" provision, clinical information disclosed to payers for pre-authorization purposes will be used/disclosed by only those individuals who perform the review. The only information disclosed to payers' administrative personnel should be administrative billing information on the HCFA 1500 claim form.

Administrative billing information:

Patient's name, address, date of birth, insurance information/ID number.

Clinician's name, ID number (i.e. SSN or EIN, and/or clinician's provider number) and address

Patient's diagnosis by DSM or ICD code - Axis I or "v" code; Axis II or III if relevant

Date(s), type and location of service - current and planned

Procedure code-CPT code

Charges

Clinical information for authorization of benefits:

Treatment planned - CPT code(s), including recommended/expected frequency

Currently on psychiatric medications? Y/N

Patient's status (i.e. voluntary, involuntary)

Functional status (impairment: none, mild, moderate or severe) or Axis V (GAF)

Current

Highest in past year

Estimated GAF at treatment's completion (would address treatment goal)

Level of distress (none, mild, moderate or severe) or Axis IV rating

Prognosis - the estimated minimum duration of the treatment for which authorization is sought

 

#3: Minimum necessary information for inpatient psychiatric treatment.

The third part of the "minimum necessary" guidelines for third-party payers, which follows below, concerns inpatient treatment that requires authorization for payment.

Minimum necessary information:

The following information is deemed the "minimum necessary" information that is needed by, and may therefore be disclosed to, third party payers in order for them to authorize payment for inpatient psychiatric services. Consistent with the Rule's "minimum necessary" provision, clinical information disclosed to payers for pre-authorization purposes will be used/disclosed by only those individuals who perform the review. The only information disclosed to payers' administrative personnel should be administrative billing information on the HCFA 1500 claim form.

Administrative Billing Information

Patient's name, address, date of birth, insurance information/ID number.

Patient's diagnosis by DSM or ICD code - Axis I or "v" code; Axis II or III if relevant

Clinician's name, ID number (i.e. SSN or EIN, and/or provider number) and address

Date(s), type and location of service - current and planned

Procedure code - E&M code(s) or (CPT code for ECT)

Charges

Clinical Information for Review

Patient's status (i.e. voluntary, involuntary)

Functional status (impairment: none, mild, moderate or severe) or Axis V:

Current

Highest in past year

Estimated GAF at discharge

Level of distress (none, mild, moderate or severe) or Axis IV:

Current Risk Factors

At risk for harm to self Y/N

At risk for harm to others Y/N

Currently on psychiatric medications Y/N

At risk for medical complications Y/N

Other--specify

Treatment planned: E&M code(s) or (CPT code for ECT), including recommended/expected frequency and duration

Response to treatment, patient's progress, or revision in treatment plan (for authorization of additional treatment). Describe briefly:

Inpatient treatment goal(s)

Prognosis - the estimated minimum duration of inpatient treatment for which authorization is sought

Procedure for requesting additional information:

The preceding guidelines should be sufficient in providing the necessary information to the insurer in almost every case for the purposes previously described. In rare cases, following disclosure of the above information, if the third-party payer 1) questions the patient's entitlement to benefits, or the amount of payment requested, or 2) has reasonable cause to believe the treatment in question may be neither usual, customary or reasonable, the APA recommends the following procedure:

The disputed question/issue should be referred for an independent review by a qualified psychiatrist who is independent of the insurer, whose cost will be borne by the insurer. This reviewer will be given access to the clinical information necessary for the review. However, only the reviewer's determination, (and no additional clinical information) shall be disclosed by the treating psychiatrist or the reviewer to the insurer for this purpose. Current privacy statutes in New Jersey and the District of Columbia provide a long-standing, workable model for such a procedure.

Attachments:

HCFA 1500 claim form

Washington DC and New Jersey statutes

Outpatient Treatment Report Form, page 1 - APA (12/98)

References:

Hennessy & Hennessy, An Economic and clinical rationale for changing utilization review practices for outpatient psychotherapy. ISSN:0092-8623;v24(3), 340)

The Surgeon General's Report on Mental Health (Chapter 7) December 1999

Washington DC and New Jersey Mental-Health privacy statutes

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