Clinical UM Guideline


Subject: Targeted Case Management
Guideline #:  CG-BEH-13 Publish Date:    04/25/2018
Status: Reviewed Last Review Date:    03/22/2018


This document addresses Targeted Case Management (TCM). The medical necessity criteria outlined in this document for TCM includes two categories; Severity of Illness and Continued Stay. Severity of Illness criteria includes descriptions of the member’s condition and circumstances. For continued authorization of the requested service, Continued Stay criteria must be met along with Severity of Illness criteria.

TCM is an outpatient mental health service that assists members in accessing behavioral health treatment, medical interventions, and educational, social, developmental, and other support services. The goal of TCM is to ensure access to needed services, appropriate service utilization, and treatment adherence. TCM does not include the direct delivery of these services. TCM services must be driven by the member’s mental health needs.

Note: Please see the following related document(s) for additional information:

Clinical Indications

Medically Necessary:

Severity of Illness (SI)

TCM is considered medically necessary when member has ALL of the following:

  1. The member experiences symptoms that meet the diagnostic criteria for a diagnosis from Diagnostic and Statistical manual of Mental Disorders (DSM-5) or International Classifications of Diseases (ICD) for psychiatric outpatient treatment covered by the member’s plan; and
  2. Interventions focus on the present symptoms and complaints that have led to a decrease in the member’s cognitive and behavioral functioning; and
  3. Service is for adults with severe and persistent mental illness and children and youth with serious emotional disturbance (SED); and
  4. Specific symptoms or disturbances of mood and/or behavior are present, with functional impairment, which are consistent with the DSM-5/ICD diagnosis listed, and these disturbances/symptoms make the member unable to access behavioral health treatment, medical, educational, social, developmental or other supportive services required; and
  5. The member demonstrates motivation for receiving support in accessing services and is capable of benefiting from this support; and
  6. A well-defined clinical rationale is documented that explains why the member needs assistance in accessing behavioral health treatment, medical, educational, social, developmental, or other supportive services due to their specific symptoms.

Continued Stay Criteria (CS)

TCM is considered medically necessary when member has ALL of the following:

  1. The member continues to meet Severity of Illness criteria; and
  2. Documentation of members participation and engagement in TCM; and
  3. The member is allowing coordination of care with other providers and is involving family members where indicated and evidence of this is documented; for children/adolescents, the family is participating in treatment, adhering to recommendations, and demonstrating ability to coordinate services on member’s behalf; and
  4. The member meets one of the following:
    1. Progress toward accessing needed services is documented at the expected pace given the presence of medical/physical conditions, stressors and level of support, as evidenced by adherence with treatment and support services, improving severity of symptoms and functional impairment, and continued progress is expected; or
    2. If progress is not documented, member has been re-assessed, treatment needs have been re-evaluated and changed with new linkage needs.

Not Medically Necessary:

TCM is considered not medically necessary when the above criteria are not met.


The following codes for treatments and procedures applicable to this guideline are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

Note: The following list of procedure codes are examples only and may not represent all codes being used for targeted case management. Please contact the member's plan for applicable coding conventions as these may vary.




Targeted case management, each 15 minutes


Targeted case management; per month



ICD-10 Diagnosis



For the following diagnoses, including but not limited to:


Mental, behavioral, and neurodevelopmental disorders

Discussion/General Information

TCM services facilitate and support access to care. The services are designed to meet the needs of adults with severe and persistent mental illness as well as children, adolescents and families of children and adolescents with serious emotional disorders. Unlike direct treatment, TCM facilitates service access, then supports adherence with treatment plans. The primary focus is on mental health and substance abuse services.  Incorporation of management of illnesses outside of the behavioral health sphere can be an important element in TCM, in part recognition of the growing acceptance of the importance of non-behavioral health care.

Standard components of TCM include:

Standard outcomes of TCM include:

Certain conditions should be in place for effective provision of TCM. A comprehensive case management assessment is completed face to face prior to the provision of case management services. The assessment includes identifying information, family life, physical health, emotional health, social relationships, physical environments, self-care, educational status, legal status, financial resources, and community resources. A person-centered treatment plan should be created to address behavioral health treatment, medical, educational, social, developmental and or other supports to be accessed by member. The case manager should have a plan to assist with access to treatment plan services and resources. Treatment goals should target resolution of specific symptomatic or stabilization of mood and/or behavior consistent with the DSM-5/ICD diagnoses listed, focus on ensuring access and coordinating to needed services. Discharge plans should be individualized and include a projected discharge date. Medication needs are being monitored and treatment needs for the member are coordinated. Training addressing substance use/dependence should be provided when a diagnosis of substance use disorder is present and coordination with appropriate treatment providers is documented. Care is coordinated with the primary care provider and is documented. Coordination of care with other clinicians providing care to the member including psychiatrist/therapist should be documented. TCM promotes communication between all involved providers. Community/natural supports and resources should be identified and utilized. Skills training should include the development of and communication with community/natural supports, including school/work, self-help or diagnosis specific support groups, spiritual/religious, and community recreational activities. Family participation in treatment should be documented unless contraindicated with rationale noted. Family members may be caregivers, which should be noted in the assessment and incorporated in the treatment plan. Services are typically provided in places such as the individual’s home, community organizations, and neighborhood. Providers must meet requirements, including but not limited to qualifications, caseload standards, contact frequency and duration requirements, and training requirements. Documentation must meet requirements for TCM including but not limited to monthly progress summaries. TCM services should not include any non-covered services. TCM should not be primarily for the avoidance of incarceration of the member or to satisfy programmatic length of stay (refers to a predetermined number of days or visits for a program’s length instead of an individualized determination of how long a member needs to be in that program). There should be a reasonable expectation that the member’s illness, condition, or level of functioning will be stabilized, improved, or maintained through accessing treatment and medical, educational, social, developmental, and other supportive services.


Outpatient treatment: Outpatient treatment is a level of care in which a mental health professional licensed to practice independently provides care to individuals in an outpatient setting, whether to the member individually, in family therapy, or in a group modality.

Severe Mental Illness (also known as serious and persistent mental illness): A mental, behavioral or emotional disorder according to the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders, in members 18 years and older, that results in functional impairment which substantially interferes with or limits one or more major life activities (e.g., maintaining interpersonal relationships, activities of daily living, self-care, employment, recreation) that have occurred within the last year. All of these disorders may have acute episodes as part of the chronic course of the disorder. An organization may also use its state's definition or the definition of another appropriate regulatory authority (SAMHSA, 2016).

Targeted case management: Targeted case management is used to assist adults and children who qualify for this service in maintaining access to needed medical, social, educational, and other services.


Peer Reviewed Publications:

  1. Alexopoulos GS, Raue PJ, McCulloch C, et al. Clinical case management versus case management with problem-solving therapy in low-income, disabled elders with major depression: a randomized clinical trial. AJ Geriatr Psychiatry. 2016; 24(1):50-59.
  2. Kirk TA, Di Leo P, Rehmer P, et al. A case and care management program to reduce use of acute care by clients with substance use disorders. Psychiatr Serv. 2013; 64(5):491-493.
  3. Ziguras SJ, Stuart GW. A meta-analysis of the effectiveness of mental health case management over 20 years. Psychiatr Serv. 2000; 51(11):1410-1421.

Government Agency, Medical Society, and Other Authoritative Publications:

  1. Department of Medicaid. Kentucky Medicaid Program Targeted Case Management Services Children Manual. Available at: Accessed on January 26, 2018.
  2. Dieterich M, Irving CB, Bergman H, et al. Intensive case management for severe mental illness. Cochrane Database Syst Rev. 2017;(1):CD007906.
  3. Kentucky Department of Behavioral Health, Developmental and Intellectual Disabilities. Kentucky Adult targeted case management. Available at: Accessed on January 26, 2018.
  4. Rosenbaum S. The CMS Medicaid targeted case management rule: Implications for special needs service providers and programs. Center for Health Care Strategies Inc. Available at: Accessed on January 26, 2018.
  5. Substance Abuse and Mental Health Services Administration (SAMHSA). National Registry of Evidence-based Programs and Practices. Behind the term: serious mental illness. 2016. Available at: Accessed on January 26, 2018.






Medical Policy & Technology Assessment Committee (MPTAC) review.



Behavioral Health Subcommittee review. The document header wording updated from “Current Effective Date” to “Publish Date”. Updated References section.



MPTAC review.



Behavioral Health Subcommittee review. Updated Formatting in “Clinical Indications” section. Deleted Websites for Additional Information section. Updated Discussion and References sections.



MPTAC review.



Behavioral Health Subcommittee review. Updated formatting in clinical indications section. Revised title to: Targeted Case Management. Updated Discussion, Reference and Websites sections. Removed ICD-9 codes from Coding section.



MPTAC review.



Behavioral Health Subcommittee review. Reformatted and clarified medically necessary SI and CS criteria. Removed IS criteria from medically necessary position statement and moved to the Discussion section. Description, Discussion, and Reference sections updated.



MPTAC review.



Behavioral Health Subcommittee review. Initial document development.