A Plan of Care (POC) is required for all psychiatric services, including medication management.
The initial Plan of Care (POC) shall be developed at the first appointment to address the immediate service,
health, and safety needs for the member in outpatient psychiatric settings based on the licensed practitioner
assessment in collaboration with the member.
The focus of the POC must be related to the diagnosis. The individual must have a current documented
DSM-psychiatric diagnosis which is documented along with the individual’s current mental status in the medical progress notes.
Outpatient psychiatric services shall be considered appropriate when an individual meets all of the following criteria:
Requires treatment in order to sustain behavioral or emotional gains or to restore cognitive functional levels that have been impaired.
Exhibits deficits in peer relations, dealing with authority; is hyperactive; has poor impulse control.
Is clinically depressed or demonstrates other dysfunctional clinical symptoms having an adverse impact on attention and concentration, ability to learn, or ability to participate in employment, educational, or social activities.
Medical Necessity Criteria
Accepting Medallion 4, CCC Plus, and Medicaid Fee-for-Service plans from all VA Medicaid Managed Care Organizations including Aetna Better Health of VA, Anthem Healthkeepers Plus, Magellan Complete Care of Virginia, Optima/Sentara, United Healthcare/Optum, and VA Premier.