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PAP902

Behavioral Health Prior Authorization Requirements


Provider Administrative Policy

Section
Behavioral Health
Policy Date
September 2009
Status/Date
Revised/June 2014
Provider Type(s)
Mental Health   Physician  

Disclaimer

Our provider administrative policies contain information regarding claims submission, reimbursement, and other information in order to achieve an efficient relationship with our providers. These policies are not an authorization or explanation of benefits. Blue Cross of Idaho retains the right to add to, delete from and otherwise modify this policy in accordance with our provider contracts


Policy

Behavioral Health Prior Authorization Requirements

Blue Cross of Idaho Groups and ASC policy holders may accept all, some or none of Blue Cross of Idaho's Behavioral Health Management program. To ensure proper benefits for your patient, please be sure to visit bcidaho.com and check the online benefit summary file located under benefits or call a customer service advocate (see PAP100).

Prior authorization

We perform prior authorization on a prospective basis to gather the clinical information to determine if the member's benefit plan covers the services requested. This involves working with providers to obtain the member's necessary medical records and treatment plan and determining the medical necessity for the planned services.

Please request prior authorization 10 business days prior to services.

We will deny claims submitted for behavioral health services without the required prior authorization and the contracting provider will be financially liable. Please ensure the Blue Cross of Idaho BHM department reviews and approves all services requiring prior authorization before providing the service. Denied claims due to non-compliance with the prior authorization requirement will not be eligible for post service medical necessity review even upon provider appeal.

Beginning September 1, 2014 revised provider reconsideration language:

Provider reconsideration of prior authorized denials

Blue Cross of Idaho offers providers a reconsideration review of a prior authorization denial for insufficient information to determine medical necessity. The denial letter will describe the information needed to complete the medical necessity review. Authorizations that are denied as not medically necessary or investigational based on medical policy will not be eligible for reconsideration but can be appealed through the member appeal process. A provider cannot exercise appeal rights on behalf of the member without the member's express written authorization. Our determination of the provider's request for reconsideration does not affect the member's appeal rights under his or her policy.

Blue Cross of Idaho does not offer reconsiderations for services or procedures excluded under the member contract.

Reconsideration

If a provider receives a prior authorization denial due to insufficient information to determine medical necessity, he or she can request reconsideration by submitting a written or faxed request with the requested supportive documentation to Blue Cross of Idaho's Medical Management Department within 60 days of the original authorization denial. Blue Cross of Idaho will issue a reconsideration determination within 14 calendar days of receiving the reconsideration request.

The following provider reconsideration workflow will no longer be in effect after August 31, 2014

Provider reconsideration of prior authorization denials

Blue Cross of Idaho offers provider's two levels of reconsideration review of a denied prior authorization request prior to services rendered. Blue Cross of Idaho may offer external review on a prospective review basis. Blue Cross of Idaho may offer external review on a prospective review basis. Blue Cross of Idaho does not offer reconsiderations and external review for conditions, services or procedures excluded under the member contract.

Providers must initiate reconsideration requests within 60 days of the original authorization denial letter.

Initial reconsideration

If a provider is dissatisfied with an authorization determination, he or she can request reconsideration determination within 10 business days of receiving the reconsideration request.

Subsequent reconsideration

If a provider is not satisfied with the initial reconsideration determination, the provider may submit a second written or faxed reconsideration request with additional supportive documentation to Blue Cross of Idaho's Medical Review Department. Blue Cross of Idaho will issue a reconsideration determination within 10 business days of receiving the subsequent reconsideration request.

Beyond this reconsideration process, members are responsible for appealing the adverse benefit determination. A provider cannot exercise appeal rights under his or her policy.

Where to submit a request

Fax or mail prior authorization requests on one of the appropriate prior authorization forms to:

Fax: 208-387-6840

Mail:

Blue Cross of Idaho
Attn: Behavioral Health Department
PO Box 7408
Boise, ID 83707
Confidential Request

The following mental health and substance abuse (MHSA) services require prior authorization. Please read the descriptions of each service for the prior authorization requirements.

  1. Outpatient Psychotherapy

    These services typically take place in an office setting and include individual and group psychotherapy. Services may include, but are not limited to, an initial diagnostic interview, individual, group, psychotherapy and medication management. Patients must meet DSM-IV criteria for a mental health or substance abuse diagnosis and their functioning level must meet the medical necessity criteria for outpatient care.

    Blue Cross of Idaho requires prior authorization after 10 visits for individual and group therapy that does not include medication management services.

    Please note: Some groups may have different limits for the prior authorization requirement. In that situation, Blue Cross of Idaho may request you to obtain prior authorization for individual or group therapy that does not include medication management services after the visit limit specified in their contract.

    Behavioral Health Services/Extended Care Prior Authorization Form

  2. Intensive Outpatient Therapy (IOP) - requires prior authorization

    IOP therapy includes planned, structured, service provision of at least three hours per day, three days per week and a minimum of nine hours total per week, designed to address a mental or substance related disorder. Services provided could include group, individual and family psychotherapy or psycho-educational services and adjunctive services such as medical monitoring and nutrition. Intensive outpatient services are more intensive than traditional outpatient services but less intensive than partial hospitalization.

    • Mental health intensive outpatient treatment - requires prior authorization

      Concentrated, non-residential program of education, individual, group, family therapy and education. The individual must have an ICD-9 diagnosis and his or her functioning level must qualify for this level of care based on his or her psychiatric functioning level.

      Mental Health Intensive Outpatient Program (IOP) Prior Authorization Form

    • Substance abuse intensive outpatient treatment - requires prior authorization

      Treatment involves a concentrated, nonresidential program of individual and group therapy, education and activities for a detoxified patient and his or her family with treatment characterized primarily by a group approach, which has didactic and process components. A critical component of the treatment is relapse prevention. The individual must meet DSM-IV criteria for a substance abuse disorder in order to qualify for SA-IOP. The individual must meet ASAM guidelines for level 11.1 level of care.

      Substance Abuse Intensive Outpatient Program (IOP) Prior Authorization Form

  3. Partial hospitalization - requires prior authorization

    The PHP program involves the same intensity as inpatient hospitalization (including medical and nursing) except the patient is in the program less than 24 hours. Programming is between four and eight hours a day, at least three days a week.

    A PHP is intensive outpatient treatment with less than 24 hours of daily care designed to provide individualized and attentive treatment not typically provided in a regular outpatient setting. It is for patients suffering with serious mental illness, eating disorder and/or substance abuse. Partial hospitalization provides individual and group psychotherapy, social and vocational rehabilitation, occupational therapy, assistance with educational needs and other services to help patients maintain their abilities to function at home, work and in social circles and allows them to return home on nights and weekends. The individual must meet the medical necessity criteria for partial hospitalization care.

    Mental Health Partial Hospitalization Program (PHP) Prior Authorization Form

    Substance Abuse Partial Hospitalization Program (PHP) Request Form

  4. Inpatient - requires prior authorization

    • Acute psychiatric hospitalization - requires prior authorization

      Use acute hospitalization for the following care services:

      • 24-hour intensive, psychiatric, medical and nursing care including continuous observation and monitoring

      • Acute interventions to control behavior and symptoms requiring stabilization

      • Acute management to prevent harm or significant deterioration of functioning and to ensure safety of the patient and/or others

      • Daily monitoring of medications for effects and side effects

      • A contained environment for targeted interventions that is not safe in a non-monitored setting

      • The individual must meet the medical necessity criteria for hospitalization

    • Acute hospitalization alcohol/drug detoxification - requires prior authorization

      Detoxification provides 24-hour, intensive medical and psychiatric care, nursing care, continuous observation and behavior control when needed to ensure the safety of the individual and/or others and provider a comprehensive multi-modal therapy plan for the individual and his or her family. The patient must meet the medical necessity criteria for acute hospital detoxification care.

      To request inpatient services refer to PAP100 for Behavioral Health Management contact numbers.

  5. Residential treatment - requires prior authorization

    Residential treatment is 24-hour care outside of a hospital, typically licensed at a residential intermediate level or an intermediate care facility. It offers an organized set of services, including diagnostic, medical management and monitoring, therapeutic services and daily living skills development. Treatment requires on-site nursing services and provides an individually planned regimen of care.

    • Residential treatment-mental health - requires prior authorization

      Residential treatment on a per diem basis for behavioral health issues in a residential treatment program designed to provide a 24-hour group living situation where the patient receives treatment under the care of a physician. Treatment includes: individual, group, family and millieu. Rate paid is inclusive of all services provided. The individual must meet the psychiatric medical necessity criteria for residential care.

    • Residential treatment-substance abuse - requires prior authorization

      Residential treatment on a per diem basis for substance abuse issues in a residential treatment program designed to provide a 24-hour group living situation where the patient receives treatment under the care of a physician. Residential treatment centers are intensive in nature, focus on addressing significant substance abuse problems and provide a structured recovery environment. Treatment includes: individual, group, family and millieu. Rate paid includes all services provided. The individual must meet medical necessity criteria for substance abuse residential care.

      To request residential treatment refer to PAP100 for Behavioral Health Management contact numbers.

  6. Electroconvulsive therapy (ECT) - requires prior authorization

    This procedure involves deliberately sending electric currents through the brain to trigger a brief seizure that changes the brain chemistry and alleviates symptoms of certain mental illnesses. You may recommend this therapy for patients needing rapid improvement of their mental state in conjunction with anesthesia and muscle relaxant medications. ECT is available on both an inpatient and outpatient basis. Individuals must meet DSM-IV criteria and meet the medical necessity criteria for ECT treatments.

    Electroconvulsive Therapy (ECT) Initiation Prior Authorization Form

    Electroconvulsive Therapy (ECT) Continuation Prior Authorization Form

  7. Psychological testing - requires prior authorization

    Psychological testing uses one or more standardized measurements, instruments or procedures to observe or record human behavior and requires the application of appropriate normative data for interpretation or classification. Psychological testing may guide differential diagnosis in the treatment of psychiatric disorders and disabilities. Testing may include an assessment of cognitive and intellectual abilities, personality and emotional characteristics and neuropsychological functioning. The primary reason for psychological testing is to facilitate the assessment and treatment of mental health and substance abuse disorders.

    Psychological/Neurological Testing Prior Authorization Form

  8. Neuropsychological testing

    Neuropsychological testing evaluates patients who experienced a traumatic brain injury, brain damage or organic neurological problems (e.g., dementia) or to evaluate the progress of patients who have undergone treatment or rehabilitation for  neurological injuries or illnesses.

    Psychological/Neurological Testing Prior Authorization Form


Policy History

Date Action Reason
June 2014 Revised Added provider reconsideration language
June 2012 Revised Added reconsideration language
January 2011 Revised Provider liability statement added
January 2010 Revised Inclusive group and ASC information added
November 2009 Revised Group renewal information added

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