Focused Outpatient Management Program

BCBSIL is responsible for the effective management of its members’ behavioral health benefits. That is why the Behavioral Health Focused Outpatient Management Program was developed as a new and innovative way to address the unique aspects of managing behavioral health conditions and treatment, and continue to ensure that members receive medically necessary and appropriate quality, behavioral health outpatient care. The Focused Outpatient Management Program is expected to improve coordination of care for behavioral health services.

Focused Outpatient Management is a claims-based approach to behavioral health care management that uses data-driven analysis and clinical intelligence rules to identify members whose care and treatment may benefit from further review and collaboration. The cornerstone of this model is outreach and engagement from BCBSIL to the identified providers and members to discuss treatment plans and benefit options. The goal is to collaborate with providers and members to maximize the benefits available to the member under his or her benefit plan.

There will be no change to the current BCBSIL preauthorization process; preauthorization is not required for most outpatient professional behavioral health services. However, preauthorization will continue to be required for the following outpatient behavioral health services prior to initiation of service:

  • Electroconvulsive therapy (ECT)
  • Psychological testing
  • Neuropsychological testing
  • Intensive outpatient programs (IOP)

Preauthorization will continue to be required for all inpatient, residential treatment and partial hospitalization admissions.

The benefits of Focused Outpatient Management include:

  • Helping address member needs to improve the quality of care and outcomes
  • Improving collaboration with providers on complex cases
  • Providing referrals to appropriate programs
  • Raising awareness of the availability of additional benefits, more intensive treatments, community based resources, and integrated care and condition management programs where appropriate

By identifying members who can benefit from referrals to case or condition management programs, BCBSIL helps ensure members have access to the services they need to improve both quality of care and outcomes.

The Behavioral Health program is available only to members enrolled in a BCBSIL health plan that includes behavioral health benefits through BCBSIL.