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TITLE 28INSURANCE
PART 1TEXAS DEPARTMENT OF INSURANCE
CHAPTER 3LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES
SUBCHAPTER HHSTANDARDS FOR REASONABLE COST CONTROL AND UTILIZATION REVIEW FOR CHEMICAL DEPENDENCY TREATMENT CENTERS
RULE §3.8023Admission Criteria for Outpatient Treatment Service

(a) An outpatient treatment service is defined as one consisting of at least one to two hours per week.

(b) An individual is considered eligible for treatment in an outpatient treatment service when the individual meets the conditions of paragraphs (1) through (3) of this subsection.

  (1) The diagnosis must meet the criteria for the definition of chemical dependence, as detailed in the most current revision of the International Classification of Diseases, or the most current revision of the diagnostic and statistical manual for professional practitioners, accompanied by evidence that some of the symptoms have persisted for at least one month or have occurred repeatedly over a longer period of time.

  (2) Concerning the diagnosis of alcohol/drug abuse, the individual must meet the criteria for the definition of chemical substance abuse, as detailed in either the most current revision of the International Classification of Diseases, or the most current revision of the diagnostic and statistical manual for professional practitioners.

  (3) Concerning the factors for admission to an outpatient treatment service, the patient must have met the diagnostic criteria for chemical dependency under paragraph (1) of this subsection or for abuse under paragraph (2) of this subsection, and must meet the conditions of all three subparagraphs (A)-(C) of this paragraph.

    (A) Category 1: medical functioning. The patient has no medical complications that would hamper the patient's participation in the outpatient treatment service.

    (B) Category 2: family, social, academic dysfunction. The patient must meet the criteria of at least one clause out of clauses (i) or (ii) of this subparagraph. The patient's living environment should be considered as a factor. An individual living in an environment where licit or illicit mood altering substances are being used may not be a candidate for this level of care early in episode of care (early considered the first 30 days).

      (i) The patient's social system and significant others are supportive of recovery to the extent that the patient can adhere to a treatment plan and treatment service schedules without substantial risk of reactivating the patient's addiction.

      (ii) The patient has no primary or social support system to assist with immediate recovery, but has the social skills to obtain such a support system or to become involved in a self-help fellowship.

    (C) Category 3: emotional/behavioral status. The patient must meet the criteria under all three clauses (i)-(iii) of this subparagraph.

      (i) Patient is coherent, rational and oriented for treatment.

      (ii) Mental state of the patient does not preclude the patient's ability to:

        (l) comprehend and understand the materials presented; and

        (ll) participate in rehabilitation/treatment process

      (iii) There is documentation that the patient expresses an interest to work toward rehabilitation/treatment goals.


Source Note: The provisions of this §3.8023 adopted to be effective February 14, 1999, 24 TexReg 713

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