CHILD AND ADOLESCENT DAY TREATMENT (CMH/SA):

CHILD AND ADOLESCENT DAY TREATMENT (CMH/SA):

Day Treatment is a structured treatment service in a licensed facility for children or adolescents and their families that builds 

on strengths and addresses identified needs. This medically necessary service directly addresses the child’s diagnostic and 

clinical needs, which are evidenced by the presence of a diagnosable mental, behavioral, and/or emotional disturbance (as 

defined by the DSM-IV-TR and its successors), with symptoms and effects documented in a comprehensive clinical 

assessment and the Person Centered Plan. This service is designed to serve children who, as a result of their mental health 

and/or substance abuse treatment needs, are unable to benefit from participation in academic or vocational services at a 

developmentally appropriate level in a traditional school or work setting. The provider implements therapeutic interventions 

that are coordinated with the child’s academic or vocational services available through enrollment in an educational setting.

The provider agency shall establish a Memorandum of Agreement (MOA) among the Day Treatment provider, the Local 

Management Entity, and the Local Education Agency (or private or charter school as applicable). In the event that a provider 

operates a Day Treatment program and is also a private or charter school, the provider only needs to sign an MOA with the 

LME. If the Day Treatment program (which is also a private or charter school) serves children from other LEA(s), private, or 

charter school(s) then appropriate MOA(s) should be signed with the responsible LEA(s), private, or charter school(s). If the 

LEA, private or charter school refuses to sign an MOA, the Day Treatment program will be unable to provide services in that 

catchment area. These interventions are designed to reduce symptoms, improve behavioral functioning, increase the 

individual’s ability to cope with and relate to others, promote recovery, and enhance the child’s capacity to function in an 

educational setting, or to be maintained in community based services. It is available for children 5 to 17 years of age (20 or 

younger for those who are eligible for Medicaid). Day Treatment must address the age, behavior, and developmental 

functioning of each child to ensure safety, health and appropriate treatment interventions within the program milieu. Day 

Treatment provides mental health and/or substance abuse interventions in the context of a therapeutic treatment milieu. This 

service is focused on providing clinical interventions and service to support the child in achieving functional gains that support 

the child’s integration in educational or vocational settings, is developmentally appropriate, is culturally relevant and sensitive, 

and is child and family centered. Each Child and Adolescent Day Treatment provider must follow a clearly identified clinical 

model(s) or evidence-based treatment(s) consistent with best practice. The Ship Group Community Services utilizes Cognitive 

Behavioral Therapy (CBT) as our EBP model. The clinical model(s) or Evidence-Based Practices (EBPs) is expected to 

produce positive outcomes for this population. The selected clinical model(s) or EBP(s) must address the clinical needs of 

each recipient, and those needs shall be identified in the comprehensive clinical assessment and documented in the Person 

Centered Plan. All criteria (program, staffing, clinical and other) for the Day Treatment service definition and all criteria for the 

chosen clinical model(s) or EBP(s) must be followed. Where there is any incongruence between the service definition and the 

clinical model(s) or EBP(s), the more stringent requirements must be met. Providers of Day Treatment must have completed 

the required certification or licensure of the selected model(s) (as required by the developer of the clinical model or EBP) and 

must document ongoing supervision and compliance within the terms of the clinical model(s) or EBP(s) to assure model fidelity. 

All staff participating in the delivery of the clinical model(s) or EBP(s) shall complete the training requirements of that practice 

within the first 30 days of each staff member’s date of employment to provide this service. This is in addition to the 20 hours 

of staff training that are minimally required for the delivery of the Day Treatment. All follow up training or ongoing continuing 

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education requirements for fidelity of the clinical model(s) or EBP(s) must be followed. Intensive services are designed to 

reduce symptoms and improve level of social, emotional, or behavioral functioning including but not limited to:

• Functioning in an appropriate educational setting;

• Maintaining residence with a family or community based non-institutional setting (foster home, Therapeutic 

Family Services); and

• Maintaining appropriate role functioning in community settings.

Day Treatment implements developmentally appropriate direct preventive and therapeutic interventions to accomplish the 

goals of the Person Centered Plan, as related to the mental health or substance abuse diagnosis. These interventions include,

but are not limited to, the following:

• Development of skills and replacement behaviors which can be practiced, applied, and continually addressed with treatment staff 

in a therapeutic and educational environment;

• Monitoring of psychiatric symptoms in coordination with the appropriate medical care provider;

• Identification and self-management of symptoms/behaviors;

• Development/improvement of social and relational skills;

• Enhancement of communication and problem-solving skills;

• Relapse prevention and disease management strategies;

• Individual, group and family counseling;

• Provision of strengths-based positive behavior supports; and

• Psychoeducation, and training of family, unpaid caregivers, and/or others who have a legitimate role in addressing the needs 

identified in the Person Centered Plan.

Note: Psychoeducation services and training furnished to family members and/or caregivers must be provided to, or directed 

exclusively toward the treatment of, the eligible individual. Psychoeducation imparts information to children, families, 

caregivers, and/or other individuals involved with the child’s care about the child’s diagnosis, condition, and treatment for the 

express purpose of fostering developmentally appropriate coping skills. These skills will support recovery and encourage 

problem solving strategies for managing issues posed by the child’s condition. Psychoeducational activities are performed for

the direct benefit of the Medicaid recipient and help the child develop increasingly developmentally appropriate coping skills 

for handling problems resulting from their condition. The goal of psychoeducation is to reduce symptoms, improve functioning,

and meet the goals outlined in the Person Centered Plan. In partnership with the youth, his or her family, the legally responsible 

person (as applicable), and other service providers, a Child and Adolescent Day Treatment Qualified Professional is 

responsible for convening the Child and Family Team, which is the vehicle for the person-centered planning process. The 

Child and Family Team comprises those persons relevant to the child’s successful achievement of service goals including, but 

not limited to, family members, mentors, school personnel, primary medical care provider, and members of the community 

who may provide support, structure, and services for the child. The Day Treatment provider works with other behavioral health

service providers, as well as with identified medical (including primary care and psychiatric) and non-medical providers (for 

example, the county department of social services, school, the Department of Juvenile Justice and Delinquency Prevention), 

engages community and natural supports, and includes their input in the person-centered planning process. A Day Treatment 

Qualified Professional is responsible for developing, implementing, and monitoring the Person Centered Plan, which shall 

include a crisis plan. The Day Treatment provider is also responsible for documenting the status of the child’s progress and 

the effectiveness of the strategies and interventions outlined in the Person Centered Plan. As part of the crisis plan of the 

Person Centered Plan, the Day Treatment provider shall coordinate with the Local Management Entity and recipient to assign 

and ensure “first responder” coverage and crisis response, as indicated in the Person Centered Plan, 24 hours a day, 7 days 

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a week, 365 days a year to recipients of this service. Day Treatment provides case management services including, but not 

limited to, the following:

• Assessing the child’s needs for comprehensive services

• Convening Child and Family Team meetings to coordinate the provision of multiple services and the 

development of and revisions to the PCP

• Developing and implementing the Person Centered Plan

• Linking the child and/or family to needed services and supports (such as medical or psychiatric consultations)

• Monitoring the provision of services and supports

• Assessing the outcomes of services and supports

• Collaborating with other medical and treatment providers.

For Medicaid-funded Day Treatment services, a signed service order shall be completed by a physician, licensed psychologist, 

physician assistant, or nurse practitioner according to his or her scope of practice and shall be accompanied by other required 

documentation as outlined elsewhere in this policy (DMA Clinical Coverage Policy 8A, Enhanced Mental Health and Substance 

Abuse Services). Each service order shall be signed and dated by the authorizing professional and shall indicate the date on 

which the service was ordered. A service order shall be in place prior to or on the day that the service is initially provided in 

order to bill Medicaid for the service. The service order shall be based on a comprehensive clinical assessment of the recipient’s 

needs. For State-funded services, it is recommended that a service order be completed prior to or on the day that the service 

is initially provided.

Provider Requirements

Day Treatment services shall be delivered by practitioners employed by mental health or substance abuse provider 

organizations that

• meet the provider qualification policies, procedures, and standards established by the DMA;

• meet the provider qualification policies, procedures, and standards established by the Division of Mental Health, 

Developmental Disabilities and Substance Abuse Services (DMH/DD/SAS);

• fulfill the requirements of 10A NCAC 27G; and

• are certified as a Critical Access Behavioral Healthcare Agency (CABHA) by July 1, 2010.

These policies and procedures set forth the administrative, financial, clinical, quality improvement, and information services 

infrastructure necessary to provide services. Provider organizations shall demonstrate that they meet these standards by being 

endorsed by the Local Management Entity (LME). Additionally, within one year of enrollment as a provider with DMA, the 

organization shall achieve national accreditation with at least one of the designated accrediting agencies. (Providers who were 

enrolled prior to July 1, 2008, shall have achieved national accreditation within three years of their enrollment date.) The 

organization shall be established as a legally constituted entity capable of meeting all of the requirements of the Provider 

Endorsement, Medicaid Enrollment Agreement, Medicaid Bulletins, and service implementation standards. For Medicaid 

services, the organization is responsible for obtaining authorization from Medicaid’s approved vendor for medically necessary 

services identified in the Person Centered Plan. For State-funded services, the organization is responsible for obtaining 

authorization from the LME. The Day Treatment provider organization shall comply with all applicable federal and state 

requirements. This includes but is not limited to North Carolina Department of Health and Human Services (DHHS) statutes, 

rules, policies, and Implementation Updates; Medicaid Bulletins; and other published instruction. A facility providing Day 

Treatment services shall be licensed under 10A NCAC 27G .1400 or 10A NCAC 27G .3700.

Staffing Requirements

All staff working in a Day Treatment Program must have the knowledge, skills and abilities required by

the population and age to be served. This service is delivered by the following staff:

• One (1) full time program director who meets the requirements specified for a Qualified Professional (preferably 

Master’s level or a licensed professional) and has a minimum of two years experience in child and adolescent mental 

health/substance abuse treatment services who must be actively involved in program development, implementation, 

and service delivery;. This individual may serve as one of the Qualified Professionals in the Day Treatment Program 

staffing ratio; 

AND

• a minimum of one (1) FTE Qualified Professional, per six children, who has the knowledge, skills, and abilities 

required by the population and age to be served, who must be actively involved in service delivery (for example, a 

program with four recipients needs one FTE QP, a program with seven recipients needs two FTE QPs), and a program 

with 19 recipients needs 4 FTE QPs). 

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AND

• a minimum of one (1) additional FTE (Qualified Professional, Associate Professional, or Paraprofessional) for 

every 18 enrolled recipients beginning with the 18th enrolled recipient (for example, a program with 17 recipients 

does not need the additional FTE; a program with 21 recipients needs one additional FTE; and a program with 36 

recipients needs two additional FTEs) .

AND

• a minimum of a 0.5 of a full time dedicated Licensed Professional for every 18 enrolled recipients. This individual 

must be actively involved in service delivery. A Provisionally Licensed Professional who fills this position must be fully 

licensed within 30 months from the effective date of this policy. For Provisionally Licensed Professionals hired after 

the effective date of this policy, the 30-month timeline begins at date of hire. For substance abuse focused programs, 

the Licensed Professional must be an LCAS (For example, a program with 10 recipients needs one 0.5 LP; a program 

with 19 recipients needs one full time LP).

Although the Licensed Professional is in addition to the program’s Qualified Professional to child ratio, he or she may serve, 

as needed, as one of the two staff when children are present. A minimum ratio of one Qualified Professional to every six (6) 

children is required to be present, with a minimum of two (2) staff present with children at all times. The exception is when only 

one child is in the program, in which case only one (1) staff member is required to be present. The staffing configuration must 

be adequate to anticipate and meet the needs of the recipients receiving this service. If, for additional staffing purposes, the 

program includes persons who meet the requirements specified for Associate Professional or Paraprofessional status 

according to 10A NCAC 27G.0104, supervision must be provided according to supervision requirements specified in 10A 

NCAC 27G.0204 and according to licensure requirements of the appropriate discipline. Each staff member providing Day 

Treatment must complete a minimum of 20 hours of training, including the components of the Day Treatment service definition, 

crisis response, clinical model(s) implemented, Person Centered Thinking, and System of Care (SOC) Child and Family Team 

training within the first 30 days of each staff member’s date of employment to provide this service.

Service Type/Setting

A facility providing Day Treatment services shall be licensed under 10A NCAC 27G .1400 or 10A NCAC 27G .3700. This is a 

day/night service that shall be available year round for a minimum of three hours a day during all days of operation. During the 

school year, the Day Treatment Program must operate each day that the schools in the local education agency, private or 

charter school, are in operation, and the Day Treatment operating hours shall cover at least the range of hours that the LEAs, 

private or charter schools operate. Day Treatment may include time spent off site in places that are related to achieving service 

goals such as normalizing community activities that facilitate transition/integration with their school setting, visiting a local place 

of business to file an application for part time employment. As part of the crisis plan of the Person Centered Plan, the Day 

Treatment provider shall coordinate with the Local Management Entity and recipient to assign and ensure “first responder” 

coverage and crisis response, as indicated in the Person Centered Plan, 24 hours a day, 7 days a week, 365 days a year to 

recipients of this service. Day Treatment shall be provided in a licensed facility separate from the child’s residence. This is a 

facility based service and is provided in a licensed and structured program setting appropriate for the developmental age of 

children and adolescents. No more than 25% of treatment services for an individual per agency work week may take place 

outside of the licensed facility. This shall be documented and tracked by the provider for each child.

Program Requirements

Each Child and Adolescent Day Treatment provider must follow a clearly identified clinical model consistent with best practice. 

This model must be specified and described in the provider’s program description. This clinical model should be expected to 

produce positive outcomes for this population. The Day Treatment Program staff collaborates with the school and other service 

providers prior to admission and throughout service duration. The roles of Day Treatment staff and educational/academic staff

are established through the MOA between the Day Treatment provider, the Local Management Entity, and the Local Education 

Agency (or private or charter school as applicable). Designation of educational instruction and treatment interventions is 

determined based on staff function, credentials of staff, the child’s Person Centered Plan, and the IEP/504 plan. Educational 

instruction is not billable as Day Treatment. The therapeutic milieu should reflect integrated rehabilitative treatment and 

educational instruction. Day Treatment is time limited and services are tTARated based on the transition plan in the Person 

Centered Plan. Transition and discharge planning begins at admission and must be documented in the Person Centered Plan. 

While Day Treatment addresses the mental health and/or substance symptoms related to functioning in an educational setting, 

family involvement and partnership is a critical component of treatment as clinically indicated.

Eligibility Criteria

Children five through 17 (20 or younger for those who are eligible for Medicaid) are eligible for this service when:

A. There is an Axis I or II MH/SA diagnosis (as defined by the DSM-IV-TR or its successors), other than a sole 

diagnosis of a developmental disability.

AND

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B. For children with a substance abuse diagnosis, the American Society of Addiction Medicine Patient Placement 

Criteria (ASAM-PPC) are met for Level II.1.

AND

C. Both of the following shall apply:

1. Evidence that less restrictive MH/SA rehabilitative services in the educational setting have been 

unsuccessful as evidenced by documentation from the school (e.g., Functional Behavioral Assessment, 

Functional Behavioral Plan, Individual Education Plan, 504 Plan, behavior plans).

2. The child exhibits behavior resulting in significant school disruption or significant social withdrawal.

AND

D. The child is experiencing mental health and/or substance abuse symptoms (not solely those related to an 

individual’s diagnosis of developmental disability) related to his/her diagnosis that severely impair functional ability in 

an educational setting which may include vocational education.

AND

E. There is no evidence to support that alternative interventions would be equally or more effective, based on North 

Carolina community practice standards (Best Practice Guidelines of the American Academy of Child and Adolescent 

Psychiatry, American Psychiatric Association, American Society of Addiction Medicine).

Entrance Process

A comprehensive clinical assessment that demonstrates medical necessity shall be completed prior to provision of this service. 

If a substantially equivalent assessment is available, reflects the current level of functioning, and contains all the required 

elements as outlined in community practice standards as well as in all applicable federal and state requirements, it may be

used as part of the current comprehensive clinical assessment. Relevant diagnostic information shall be obtained and included

in the Person Centered Plan. For Medicaid-funded Day Treatment services, a signed service order shall be completed by a 

physician, licensed psychologist, physician assistant, or nurse practitioner according to his or her scope of practice and shall 

be accompanied by other required documentation as outlined elsewhere in this policy (DMA Clinical Coverage Policy 8A, 

Enhanced Mental Health and Substance Abuse Services). Each service order shall be signed and dated by the authorizing 

professional and shall indicate the date on which the service was ordered. A service order shall be in place prior to or on the 

date that the service is initially provided in order to bill Medicaid for the service. The service order shall be based on a 

comprehensive clinical assessment of the recipient’s needs. For State-funded services, it is recommended that a service order 

be completed prior to or on the day that the service is initially provided. Prior authorization is required prior to or on the first 

date of this service. For Medicaid-funded Day Treatment services, prior authorization by the Medicaid-approved vendor is 

required. To request the initial authorization, the Day Treatment provider must submit the Person Centered Plan with signatures 

and the required authorization request form to the Medicaid-approved vendor. For State-funded Day Treatment services, prior 

authorization by the LME is required. To request the initial authorization, the Day Treatment provider must submit a Person 

Centered Plan with signatures and the required authorization request form to the LME. Medicaid or State funds may cover up 

to 60 days for the initial authorization period, based on medical necessity documented in the individual’s Person Centered 

Plan, the authorization request form, and supporting documentation. Requests for reauthorization may be submitted by the 

Day Treatment Program provider. In partnership with the youth, his or her family, the legally responsible person (as applicable), 

and other service providers, a Child and Adolescent Day Treatment Qualified Professional is responsible for convening the 

Child and Family Team monthly.

Continued Service Criteria

The desired outcome or level of functioning has not been restored, improved, or sustained over the time frame outlined in the

youth’s Person Centered Plan; or the youth continues to be unable to function in an appropriate educational setting, based on 

ongoing assessments, history, and the tenuous nature of the functional gains.

AND

One of the following applies:

A. The child has achieved current Person Centered Plan goals, and additional goals are indicated as 

evidenced by documented symptoms.

B. The child is making satisfactory progress toward meeting goals and there is documentation that supports that 

continuation of this service will be effective in addressing the goals outlined in the Person Centered Plan.

C. The child is making some progress, but the specific interventions in the Person Centered Plan need to be modified 

so that greater gains, which are consistent with the child's pre-morbid level of functioning, are possible.

D. The child fails to make progress, or demonstrates regression, in meeting goals through the interventions outlined 

in the Person Centered Plan. The child’s diagnosis should be reassessed to identify any unrecognized co-occurring 

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disorders, and interventions or treatment recommendations should be revised based on the findings. This includes 

consideration of alternative or additional services.

Discharge Criteria

Any one of the following applies:

A. The child has achieved goals and is no longer in need of Day Treatment services.

B. The child’s level of functioning has improved with respect to the goals outlined in the Person

Centered Plan, inclusive of a plan to transition to a lower level of care and/or appropriate educational 

setting.

C. The child is not making progress or is regressing, and all reasonable strategies and interventions have been 

exhausted, indicating a need for more intensive services.

D. The child or legally responsible person no longer wishes to receive Day Treatment services.

E. The child, based on presentation and failure to show improvement despite modifications in the Person Centered 

Plan, requires a more appropriate best practice treatment modality based on North Carolina community practice 

standards (for example, National Institute of Drug Abuse, American Psychiatric Association). In addition, a completed 

LME Consumer Admission and Discharge Form must be submitted to the LME.

Note: Any denial, reduction, suspension, or termination of service requires notification to the child and/or legally responsible 

person about their appeal rights in accordance with the Department’s recipient notices procedure.

Expected Clinical Outcomes

The expected clinical outcomes for this service are specific to recommendations resulting from clinical assessments and 

meeting the identified goals in the child’s Person Centered Plan. Expected clinical outcomes may include, but are not limited

to the following:

• Improved social, emotional, or behavioral functioning in an appropriate educational setting;

• Integration or reintegration into an appropriate educational or vocational setting;

• Reduced MH/SA symptomatology;

• Improvement of behavior, anger management, and/or developmentally appropriate coping skills;

• Development/improvement of social and relational skills;

• Enhancement of communication and problem-solving skills;

• Increased identification and self-management of triggers, cues, and symptoms and decreased frequency or intensity 

of crisis episodes;

• Engagement in the recovery process, for children with substance related disorders,

• Reduction of negative effects of substance use and/or psychiatric symptoms that interfere with the child’s daily living

• Maintaining residence with a family or community based non-institutional setting (foster home, therapeutic family 

services);

• Reduction in behaviors that require juvenile justice involvement

• Increased use of available natural and social supports

Documentation Requirements

Refer to DMA Clinical Coverage Policies and the DMH/DD/SAS Records Management and Documentation Manual for a 

complete listing of documentation requirements. For this service, the minimum documentation requirement is a full service 

note for each date of service, written and signed by at least one of the persons who provided the service. That note shall 

include the following:

• Child’s name

• Service record number

• Medicaid identification number

• Service provided (for example, Day Treatment services)

• Date of service

• Place of service

• Other staff involved in the provision of the service

• Type of contact (face-to-face, telephone call, collateral)

• Purpose of the contact

• Description of the provider’s interventions

• Amount of time spent performing the interventions

• Description of the effectiveness of the interventions in meeting the recipient’s specified goals as outlined in the 

Person Centered Plan

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•Signature and credentials of the staff member(s) providing the service (for paraprofessionals, position is required in 

lieu of credentials with staff signature)

A documented discharge plan shall be developed with the child, family/caregiver, and Child and Family Team and included in 

the service record. In addition, a completed LME Consumer Admission and Discharge Form must be submitted to the LME.

Utilization Management

Services are based upon a finding of medical necessity, must be directly related to the child’s diagnostic and clinical needs, 

and are expected to achieve the specific rehabilitative goals specified in the individual’s Person Centered Plan. Medical 

necessity is determined by North Carolina community practice standards as verified by independent Medicaid consultants for 

Medicaid-funded services, or by the LME for state-funded services. Medically necessary services are authorized in the most 

cost-efficient mode, as long as the treatment that is made available is similarly efficacious to services requested by the child’s 

physician, therapist, or other licensed practitioner. Typically, a medically necessary service must be generally recognized as 

an accepted method of medical practice or treatment. Each case is reviewed individually to determine if the requested service 

meets the criteria outlined under EPSDT. For Medicaid, authorization by the Medicaid-approved vendor is required according 

to published policy. For State-funded Day Treatment services, authorization is required by the LME prior to the first visit. The 

Medicaid-approved vendor or the LME will evaluate the request to determine if medical necessity supports more or less 

intensive services. Medicaid or State funds may cover up to 60 days for the initial authorization period based on the medical 

necessity documented in the individual’s Person Centered Plan, the authorization request form, and supporting documentation. 

Submit the reauthorization request before the initial authorization expires. Medicaid- or State-funded services cover up to 60 

days for reauthorization based on the medical necessity documented in the required Person Centered Plan, the authorization 

request form, and supporting documentation. If continued Day Treatment services are needed at the end of the initial 

authorization period, the Day Treatment provider must submit the Person Centered Plan and a new request for authorization 

reflecting the appropriate level of care and service to the Medicaid-approved vendor for Medicaid services, or to the LME for 

State-funded services. This should occur before the authorization expires.

Services are billed in one hour increments.

Service Exclusions and Limitations

The child may receive Day Treatment services from only one Day Treatment provider organization during any active 

authorization period for this service. The following are not billable under this service:

• Transportation time (this is factored in the rate)

• Any habilitation activities

• Child care

• Any social or recreational activities (or the supervision thereof)

• Clinical and administrative supervision of staff (this is factored in the rate)

• Educational instruction

Service delivery to individuals other than the recipient may be covered only when the activity is directed exclusively toward the 

benefit of that recipient. Day Treatment services may not be provided during the same authorization period as the following 

services:

• MH/SA Targeted Case Management

• Intensive In-Home Services;

• Multisystemic Therapy;

• Individual, group and family therapy;

• Substance Abuse Intensive Outpatient Program;

• Child Residential Treatment services–Levels II (Program Type) through IV;

• Psychiatric Residential Treatment Facility (PRTF);

• Substance abuse residential services; or

• Inpatient hospitalization.

Day Treatment shall be provided in a licensed facility separate from the child’s residence.

Note: For recipients under the age of 21, additional products, services, or procedures may be requested even if they do not 

appear in the N.C. State Plan or when coverage is limited to those over 21 years of age. Service limitations on scope, amount, 

or frequency described in the coverage policy may not apply if the product, service, or procedure is medically necessary. [See 

Section 2.2, EPSDT Special Provision, in this policy (Clinical Coverage Policy 8A, Enhanced Mental Health and Substance 

Abuse Services).