Question

You have received a claim from an in-network, licensed psychiatric mental health center that provides services in a clinically managed high intensity residential treatment setting. The health plan member, Brian, is being treated for an impulse control disorder that is classified as a mental health condition in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V). The disorder is listed only as a mental health condition and is not dually listed elsewhere in the most current version of International Classification of Diseases, Clinical Modification (which is used for diagnosis coding). Do you approve or deny the claim?

Group of answer choices
Approve
Deny

Answer 1

the claim from the in-network, licensed psychiatric mental health center that provides services in a clinically managed high intensity residential treatment setting for the health plan member, Brian, who is being treated for an impulse control disorder that is classified as a mental health condition in the DSM-V should be approved. The disorder is listed only as a mental health condition and is not dually listed elsewhere in the most current version of International Classification of Diseases, Clinical Modification (which is used for diagnosis coding). Therefore, it meets the criteria for coverage under the health plan.