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Provider and Facility Reference Manual

Section 18 - Behavioral Health and Chemical Dependency


Highmark Blue Cross Blue Shield of Western New York Behavioral Health Utilization Management department performs all the following inpatient and outpatient utilization review services for Blue Cross Blue Shield members when required:

  • Prior authorization
  • Level of care determinations
  • Medical necessity determinations
  • BH out-of-plan (OOP) referral requests
  • Claims review and determinations

Behavioral Health Utilization Management follows the same regulatory requirements and processes for behavioral health services and medical services, as outlined in Section 5 Utilization Management. This information is used in conjunction with the UM Program Description.  

For questions relating to any behavioral health services, you can call 1-877-837-0814. You will be directed to the appropriate area.

Clinical Criteria

Determinations are based upon Change Health Care InterQual® Criteria, OASAS Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) tool for Substance Use Disorders, Corporate Medical Protocol, Criteria Hierarchy, and/or physician medical judgment.

Utilization review shall not be conducted more frequently than is reasonably required to assess whether the health care services under review are medically necessary. Medical necessity is related to activities which may be justified as reasonable, necessary, and/or appropriate, based on evidence‐based clinical standards of care.

When making a determination of coverage based on medical necessity, the Plan considers at least the following factors when applying criteria to a given individual:

  • Age
  • Co‐morbidities
  • Complications including risk factors and functional status
  • Progress of treatment
  • Psychosocial factors
  • Home environment/availability and adequacy of supports (when applicable)

The Plan also considers characteristics of the local delivery system that are available for the particular member; such as, the availability of skilled nursing facilities, subacute care facilities, residential treatment facilities, outpatient services, or home care and community supports in the service area to support the member after discharge.

If medical necessity criteria fails at the primary review, a secondary review with the plan Medical Director is required. Additional information is obtained and provided to the Medical Director for second level review. Additional Information includes:

  • Support systems are local and accessible/adequate to meet member /parent-child needs
  • Availability of stable housing, homelessness
  • Living environment, changes in job/school, domestic violence, high risk drug use, illegal or unsanitary conditions
  • Prior attempts at living independently
  • Recent death or heath status of immediate family member, care taker,
  • Prior treatment history –episodes of care, successful treatment episodes, impulse control, ability to self-manage
  • Engagement and acceptance, member/care giver understands illness and functional limitations, participation in treatment and recovery plan, ability to assist/implement interventions, acceptance of own responsibility to participate in recovery process

Emergency Services

Emergency services, including Comprehensive Psychiatric Emergency Program (CPEP) and Office of Mental Health/ Office of Alcoholism and Substance Abuse Services (OMH/OASAS) Crisis Intervention and OMH/OASAS specific non-urgent ambulatory services are not subject to prior approval.

Definition of Emergency Care

Emergency condition means a medical or behavioral condition, the onset of which is sudden, that manifests itself by symptoms of sufficient severity, including severe pain, that a prudent layperson, possessing an average knowledge of medicine and health, could reasonably expect the absence of immediate medical attention to result in (a) placing the health of the person afflicted with such condition in serious jeopardy, or in the case of a behavioral condition, placing the health of such person or others in serious jeopardy; (b) serious impairment to such person’s bodily functions; (c) serious dysfunction of any bodily organ or part of such person; or (d) serious disfigurement of such person.

Preauthorization/Authorization Requirement for Mental Health Services



1. Behavioral Health Utilization Management – Acute Care Inpatient Psychiatric Admissions *

Prior authorization of a new admission to acute inpatient psychiatric facility are determined according to the requirements of an insurance policy. For admissions where the member benefit plan is subject to utilization management, or predefined clinical and/or quality improvement-based triggers are present as defined in the NY State OMH guiding principles, Utilization Management activities will begin at admission.

When an admission is NOT subject to utilization management per the insurance policy, or there are NO member complexity /provider quality triggers, the acute inpatient psychiatric facility is required to provide notification of the admission within two (2) business days of the admission.

An authorization is entered to ensure claims payment.

Ongoing clinical conversations are required between the Plans UM clinician, and the facility representative throughout the admission to ensure coordination of care and discharge planning occur.

Provider failure to notify the Plan of an admission within two business days may also result in Utilization Review (admission, retrospective) even if the admission would not be subject to Utilization Management due to absence of member complexity /provider quality based triggers present.

In those instances, where Utilization Review will be done, the Utilization Management process outlined consistent with medical UM process, will be followed.

Triggers for Utilization Management: Member Complexity Triggers:        

  • High utilization of psychiatric inpatient or emergency department (ED) services in the past year including three (3) or more psychiatric inpatient hospitalizations over the past 12 months, four (4) or more psychiatric ED visits in the past 12 months, or any combination of four (4) or more of psychiatric inpatient and/or psychiatric ED visits in the past 12 months. Three (3) or more medical inpatient admissions within the past 12 months.
  • Inpatient psychiatric readmission within 30 days of discharge from a psychiatric inpatient unit.
  • Length of stay exceeding 30 days.

Level of care clinical discussions will continue throughout the stay to ensure care management, discharge planning occurs. If level of care concern is identified, the facility’s Utilization Review contact person is notified; otherwise, continuous approval is assumed in the absence of notification.

Level of Care concerns are discussed with a Medical Director and/or physician reviewer to identify opportunity for case management intervention, discharge planning, and care coordination. The provider/facility can request a discussion with our Medical Director and/or physician reviewer for a level of care concern.

*Admission to non-acute, elective level of care, will continue to follow Utilization Review requirements

Please verify all preauthorization/authorization requirements at wnyhealthenet.com

2. NY State Legislation Inpatient Psychiatric Admissions for under age 18
(For applicable plans and contracted providers)

No preauthorization or concurrent review is required for the initial 14 days of medically necessary inpatient psychiatric admissions for those who have not yet reached the age of 18, in a facility that is licensed by the NY State Office of Mental Health and is participating in the Blue Cross Blue Shield network. Although preauthorization is not required, facilities are required to provide the health plan with notification of the admission, and the initial treatment plan, within 2 business days of admission and participate in periodic consultation with the plan.

  • If the facility fails to notify the health plan of either the inpatient admission or the initial treatment plan within 2 business days of the admission, the health plan may begin concurrent review immediately upon learning of the admission, even if it is during the initial 14 day period.
  • All care may be reviewed retrospectively and may be denied if not medically necessary. If coverage is denied retrospectively, the member is held financially harmless, except for allowable co-pay and deductible amounts.

All other inpatient facilities or benefit plans that are not covered by the above NYS Legislation require clinical review/authorization.

Level of Care reviews are performed throughout the inpatient stay and can be managed by either on‐site, phone, or fax review. When conducting a review, if level of care concerns are identified, the facility’s Utilization Review contact person is notified; otherwise, continuous approval is assumed in the absence of notification.

Level of Care concerns are discussed with a Medical Director and/or physician Reviewer to identify opportunity for case management intervention, discharge planning, and care coordination. The provider/facility can request a discussion with our Medical Director and/or physician reviewer for a level of care concern.  

Please verify all preauthorization/authorization requirements at wnyhealthenet.com

Preauthorization/Authorization Requirement for Substance Use Disorder Services

 

NY State Opioid Legislation SUD
Inpatient/Facility Admissions

(For applicable plans/contracted providers)

No preauthorization or concurrent review is required for the initial 28 days of medically necessary inpatient treatment for SUD in New York State Office of Alcoholism and Substance Abuse Services (OASAS) licensed facilities that are participating in the Blue Cross Blue Shield network.

Levels of care include detoxification, inpatient rehabilitation, and residential treatment. Although preauthorization is not required, facilities are required to provide the health plan with notification of the admission and the initial treatment plan within 2 business days of admission.

  • The facility is also required to perform daily clinical review, including “periodic consultation” with the plan to ensure the facility is using the OASAS Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) tool.
  • If the facility fails to notify the health plan of either the inpatient admission or the initial treatment plan within 2 business days of the admission, the health plan may begin concurrent review immediately upon learning of the admission, even if it is during the initial 28-day period.
  • All care may be reviewed retrospectively and may be denied if not medically necessary. If coverage is denied retrospectively, the member is held financially harmless, except for allowable co-pay and deductible amounts.

Request for Inpatient SUD prior to discharge from inpatient admission

The Plan will make a determination regarding a request for inpatient SUD treatment within 24 hours of receiving the request (if required per contract), provided the request is submitted to the UR agent at least 24 hours before discharge from the inpatient admission.

The Plan will provide coverage for the inpatient treatment while the determination is pending. Expedited review process is not limited to discharges from an inpatient hospital, and applies to all inpatient facilities, transfers between, and continued stay requests covered under the contract.

All other inpatient facilities or benefit plans that are not covered by the above NYS Opioid Legislation require review/authorization.

Level of Care Review

Level of Care reviews are performed throughout the inpatient stay and can be managed by either on‐site, phone, or fax review. When conducting a review, if level of care concerns are identified, the facility’s Utilization Review contact person is notified; otherwise, continuous approval is assumed in the absence of notification.

Level of Care concerns are discussed with a Medical Director and/or physician reviewer to identify opportunity for case management intervention, discharge planning, and care coordination. The provider/facility can request a discussion with our Medical Director and/or physician reviewer for a level of care concern.

Please verify all preauthorization/authorization requirements at wnyhealthenet.com.

Outpatient Preauthorization Process

Routine outpatient mental health and substance use disorder services in a members benefit year do not require preauthorization/authorization for most plans. Please verify all preauthorization/authorization requirements at wnyhealthenet.com

No registration or preauthorization/authorization is required for routine mental health or substance use outpatient visits in a member’s benefit year.

Please be advised that a few ASO/self-funded plans have elected to continue requiring registration at the first visit and medical necessity review.

Typical preauthorization workflow:

  1. Please verify all preauthorization requirements at wnyhealthenet.com
  2. Behavioral health services should be rendered and the appropriate claim for payment should be submitted.
  3. A Behavioral Health request form is located on our website under Provider/Tools and Resources/Forms/Behavioral Health Forms/Outpatient Treatment Review Form.  The form can be faxed to 1-716-887-7913, or you may call 1-877-837-0814.
  4. Highmark Blue Cross Blue Shield of Western New York reserves the right to request and review additional clinical information at any time.

Preauthorization/authorization does not guarantee payment. The member must have active coverage and the appropriate benefits at the time of the service. Please note it is the responsibility of the provider to ensure that preauthorization/authorization is in place. Requests will not be backdated for more than 30 days from the date of service.

Mental Health Parity Laws

Effective January 1, 2007, the New York State Mental Health Parity law—Timothy’s Law— was implemented. The law mandates that mental health benefits be aligned with the medical benefits in a member’s policy. Copayments, coinsurance and deductibles, benefit structures, and network requirements for mental health services cannot be any more restrictive than for medical benefits. On October 3, 2009, Federal Mental Health parity regulations became effective. The Federal law broadened the NYS mandate to include substance use disorder services and added specific requirements that changed the way member benefits and liabilities can be structured.

Please check at wnyhealthenet.org to determine what the benefit is for a particular member. Additional regulations may be published in the future.

Federal Benefits
Under Federal Parity, most Commercial policies carry an unlimited, medically necessary mental health and substance use disorder benefit for both inpatient and outpatient services. The copay/coinsurance varies under Federal guidelines, therefore it is important to verify at wnyhealthenet.com or contact Provider Service.

ASO/Self-Funded Benefit Plans
Please be advised that a few self-funded plans have elected to continue requiring registration at the first visit and medical necessity review. Please verify all preauthorization requirements at wnyhealthenet.com

Claims Submission and Provider Tools

Billing instructions are the same for all providers. Please see Section 13.

Blue Cross Blue Shield has created a variety of tools to help the staff in providers' offices understand our contract benefits, claims and preauthorization submission procedures and Service departments. Some of the tools available for your use are:

HEALTHeNET

HEALTHeNET is an online community health information network established by an independently incorporated coalition of health insurance plans, including our plan and hospital providers.

Some of the standard set of transactions available online are as follows:

Eligibility Transaction (270/271)

The eligibility transaction gives offices a direct connection to membership files and allows providers to confirm patients' eligibility in just minutes.

  • The group size (small or large) is displayed on HEALTHeNET
  • The month and day of each group’s benefit renewal is displayed in the MMDD format. For example, June 1 is shown as 0601. This assists providers in determining when a member’s benefit renews.

Claim Status Transaction (276/277)

This feature allows you to check the status of your claims. Providers are enabled able to obtain detailed information about claims, eliminating the need to contact the Provider Service Department.

Please go to wnyhealthenet.com to enroll. Additional tools are added to the website from time to time.

Highmark Blue Cross Blue Shield of Western New York Provider Website

Our website contains a variety of forms and information that will help you manage your practice. Online information includes:

  • Provider referral form and instructions
  • Provider request forms – BH OOP referral request, outpatient treatment reports
  • Provider and Facility Reference Manual
  • Blue Bulletin
  • Billing guidelines
  • Guideline for accessing autism benefits