(1) Medicaid reimbursement is not available for outpatient partial hospitalization services unless the provider submits to the department or its designee in accordance with these rules a complete and accurate Certificate of Need, certifying that:

(a) the recipient is experiencing psychiatric symptoms of sufficient severity to create severe impairments in educational, social, vocational, and/or interpersonal functioning;

(b) the recipient cannot be safely and appropriately treated or contained in a less restrictive level of care;

(c) proper treatment of the beneficiary's psychiatric condition requires acute treatment services on an outpatient basis under the direction of a physician;

(d) the services can reasonably be expected to improve the recipient's condition or prevent further regression; and

(e) the recipient has exhausted or cannot be safely and effectively treated by less restrictive alternative services, including day treatment services or a combination of day treatment and other services.

(2) For recipients determined Medicaid eligible by the department as of the time of admission to the partial hospitalization program, the Certificate of Need required under (1) must be:

(a) completed, signed and dated prior to, but no more than 30 days before, admission; and

(b) made by a team of health care professionals that has competence in diagnosis and treatment of mental illness and that has knowledge of the recipient's situation, including the recipient's psychiatric condition. No more than one member of the team of health care professionals may be professionally or financially associated with a partial hospitalization program. The team must include:

(i) a physician that has competence in diagnosis and treatment of mental illness, preferably in psychiatry;

(ii) a licensed mental health professional; and

(iii) an intensive case manager employed by a mental health center or other individual knowledgeable about local mental health services as designated by the department.

(3) For recipients who are being transferred from a hospital's acute inpatient program to the same facility's partial hospitalization program, the certificate of need required under (1) may be completed by a facility based team of health care professionals:

(a) that has competence in diagnosis and treatment of mental illness and that has knowledge of the recipient's psychiatric condition;

(b) that includes a physician that has competence in diagnosis and treatment of mental illness, preferably in psychiatry, and a licensed mental health professional; and

(c) the Certificate of Need must also be signed by an intensive case manager employed by a mental health center or other individual knowledgeable about local mental health services as designated by the department.

(4) For recipients determined Medicaid eligible by the department after admission to or discharge from the facility, the Certificate of Need required under (1) is waived. A retrospective review to determine the medical necessity of the admission to the program and the treatment provided will be completed by the department or its designee at the request of the department, a provider, the individual, or the individual's parent or guardian. Request for retrospective review must be:

(a) received within 14 days after the eligibility determination for recipients determined eligible following admission, but before discharge from the partial hospitalization program; or

(b) received within 90 days after the eligibility determination for recipients determined eligible after discharge from the partial hospitalization program.

(5) All Certificates of Need required under (1) must actually and personally be signed by each team member, except that signature stamps may be used if the team member actually and personally initials the document over the signature stamp.

(6) Prior authorization is not a guarantee of payment as Medicaid rules and regulations, client eligibility, or additional medical information on retrospective review may cause the department to refuse payment.