Expedited Psychiatric Inpatient Admission (EPIA) Policy Frequently Asked Questions

This admission policy covers any person, including a child/adolescent, who is boarding in a Massachusetts Emergency Department (ED) or Emergency Services Program (ESP), and who requires psychiatric inpatient level of care.

General Application of the Policy

Who does this policy cover?	Any person, including a child/adolescent, who is boarding in a Massachusetts Emergency Department (ED) or Emergency Services Program (ESP), and who requires psychiatric inpatient level of care.
Does this protocol apply if the individual is waiting for a level of care other than psychiatric inpatient level of care, e.g., Intensive Community-Based Acute Treatment (ICBAT), Community-Based Acute Treatment (CBAT), Acute Treatment Services (ATS), etc.?	No, this policy only applies to persons who require psychiatric inpatient level of care
If a patient is admitted due to self-injurious behavior that requires treatment on a medical floor, and subsequently is medically cleared, will this protocol apply?	No. Once a patient is admitted to a medical floor for treatment, this protocol does not apply.
Must the boarder be physically located in the ED for this policy to apply?	Boarders awaiting inpatient psychiatric level of care in other locations (home, residential programs - including the Department of Youth Services [DYS], medical floor for boarding purposes only) are also included in this protocol.
What time does the “clock start ticking” to calculate 24/48/96 hour interventions?	Time of arrival to ED.
What time does the “clock start ticking” for boarders who are waiting outside of the ED?	Time that the evaluation begins.
Can an ED/ESP contact an Insurance Carrier about one of its members as soon as it is determined that placement is needed, even if less than 24 hours?	Yes, an ED/ESP can contact an Insurance Carrier at any time. The 24-hour notification is to ensure that Insurance Carriers are made aware that they have a member boarding.
Will this protocol address issues like disagreements between an ED/ESP and an Insurance Carrier as to whether a patient meets medical necessity criteria?	No. Insurance Carriers are allowed to develop their own medical necessity criteria. If an Insurance Carrier denies a level of treatment, EDs/ESPs should follow existing internal/external appeal processes, including those coordinated by the Office of Patient Protection. This policy only applies to individuals who have been determined to need psychiatric inpatient admission.
How does this protocol relate to time periods prescribed for admissions under GL. ch. 123 §12(b)?	This protocol does not impact §12(b) time periods. §12(b) admission requirements apply only when a patient is admitted to a DMH licensed psychiatric facility.

Escalation to Insurance Carrier and Department of Mental Health (DMH)

Who coordinates responses if the patient has commercial insurance, MassHealth, and/or is a DMH client?	The patient’s primary Insurance Carrier is responsible for coordinating escalation responses under this protocol. If the patient has primary coverage by a commercial Carrier, with secondary MassHealth coverage (Third Party Liability or TPL), then the commercial Carrier has primary responsibility. If the patient has MassHealth but no commercial TPL coverage, then the MassHealth Carrier has primary responsibility. Coordination on behalf of DMH clients is determined by insurance coverage, as for any individual.
If the Insurance Carrier works with a vendor who can assist with this requirement, is that acceptable to meet compliance?	Yes. A vendor may take the lead with assisting in the process; however, the Insurance Carrier is responsible for the oversight of the vendor and for ensuring that the vendor is in compliance with all requirements.
What are the expectations around responses by Insurance Carriers and the Department of Mental Health (DMH) if the escalation request is made after business hours, on weekends, or on holidays?	If the time to initiate a Request for Assistance to Insurance Carriers, or escalation to DMH occurs after normal business hours, the Insurance Carrier or DMH is expected to respond by the following morning.
Is there a list of contacts for Massachusetts Insurance Carriers? Who should I call if the Insurance Carrier is out of state?	The list of Massachusetts Insurance Carriers is on the DMH website mass.gov/dmh. Click on the button for Expedited Admissions Policy. For out-of-state Insurance Carriers, ED/ESP should contact the number on the patient’s health coverage card.
What if the patient has no insurance or the Insurance Carrier does not get engaged because the coverage is through Medicare, a Carrier not regulated by the Division of Insurance (such as an self-insured plan), or an out-of-state Insurance Carrier?	If the patient has no insurance or engaged Insurance Carrier, the ED/ESP continues to facilitate placement through its normal course of business. If after 96 hours an appropriate placement has not been identified, the ESP/ED escalates the placement to DMH via the secure web referral tool.
If a bed is not available in an Insurance Carrier’s in-network, will that Insurance Carrier be required to look for beds out of network?	Yes, insurance carriers must look out of network if no in-network placement is available. Please see the Division of Insurance Bulletin 2018-01 (Emergency Boarding) which sets forth expectations for Insurance Carriers.
If a specific location is requested due to patient or family preference (including transportation issues), will the Insurance Carrier and DMH advocate for admission to that facility?	The Insurance Carrier will advocate and try to eliminate barriers, but the protocol does not apply if the patient or the patient’s family is unwilling to consider additional facilities.
Where is the link to DMH’s portal located? Is there training available on using the portal?	The link can be found on the DMH website: Mass.gov/DMH. Click on the button for Expedited Inpatient Admissions. Training materials are also available at that site.
How will the “most appropriate” facilities be selected when escalating to DMH?	DMH will engage facilities determined to be most appropriate by the Insurance Carrier. Additional considerations include: clinical needs of patient as determined by the evaluation team; Insurance Carrier, collateral, and other stakeholder recommendations; and barriers identified at specific facilities.
How will the ED know that the protocol has been implemented and how it is progressing?	If an ESP has escalated the process, the ESP will be responsible for keeping the ED informed. If a hospital ED Clinician is handling the case, it will be that person’s responsibility to keep the ED updated. The Insurance Carrier is expected to remain in communication with the ED/ESP throughout the process and provide updates to the ED/ESP. Similarly, an ED/ESP should communicate any changes in a patient’s status to the patient’s Insurance Carrier.

Compliance

Will data be collected to identify repetitive issues (payment, specific hospitals refusing, etc.) and focus on ways to mitigate those?	Yes. DMH is in the process of developing requirements for data collection that DMH will use to monitor compliance, track issues, and identify the needs of the Commonwealth.
Will data be kept on hospitals that have accepted challenging patients in less than 96 hours?	That data is currently maintained for MassHealth boarders via the MABHA website. Additionally DMH is in the process of developing requirements for data collection related to Inpatient Unit acuity and admission decisions which will be subject to DMH review.
Whom do I contact if I am having problems with an Insurance Carrier’s compliance with this policy and/or Bulletin 2018-01?	The Division of Insurance is responsible to ensure that insurance carriers are complying with the Expedited Admission protocols. Contact the Bureau of Managed Care phone line at Tell:[phone] or email to:[e-mail]. The calls will be forwarded to Kevin Beagan, Deputy Commissioner of Insurance, or Tracey McMillan, the Director of the Bureau of Managed Care.

Date published:	December 28, 2018
Last updated:	February 26, 2016