Behavioral Health Utilization Management Program Overview
The benefit of the full Behavioral Health Program – inpatient and outpatient management – is that it allows our Behavioral Health team to assist members throughout the entire continuum of their behavioral health care and treatment. This structure allows the Behavioral Health team to follow members as they step down from intensive levels of care (inpatient, residential, partial hospitalization) to less intensive levels (intensive outpatient, routine outpatient), ensuring that they have access to the most appropriate and effective treatment.
The Behavioral Health Program also allows the Behavioral Health team to “touch” every member who uses behavioral health care services via our state-of-the-art analytics to identify those who could potentially benefit from our array of programs and services. Our experience has been that members who have consistent support throughout all levels of behavioral health treatment are more likely to experience fewer readmissions and a more positive treatment outcome.
The Behavioral Health Program is designed to help reduce administrative burden and improve collaboration and provider satisfaction, while also helping to ensure members get the right care at the right place and time.
Management of Intensive Outpatient Services
Intensive outpatient services are managed by prior authorization and concurrent reviews. The prior authorization allows the opportunity to ensure these intensive services are medically necessary, clinically appropriate and are likely to contribute to a successful treatment outcome. This requirement applies only for members who have outpatient management as part of their behavioral health benefit plan through Blue Cross and Blue Shield of Illinois (BCBSIL). These intensive services are:
- Intensive Outpatient Programs (IOP)
- Applied Behavior Analysis (ABA)
- Outpatient Electroconvulsive Therapy (ECT)
- Repetitive Transcranial Magnetic Stimulation (rTMS)
- Psychological and Neuropsychological Testing, in some cases (BCBSIL will notify the provider if benefit prior authorization is required for these testing services).
Management of routine outpatient services:
Routine behavioral health outpatient services (individual, family, group psychotherapy, psychiatric medication management) do not require prior authorization. Instead, we have two “outlier” programs where we use our proprietary clinical analytics to “touch” every routine service without requiring the overly burdensome practice of prior authorization. These analytics allow us to identify outlier cases that might warrant a clinical quality review or benefit from additional clinical resources and/or referrals to our existing care management programs for more assistance.
Focused Outpatient Management Program:
This program is a claims-based approach to touch all routine cases through clinical logic. Clinical analytics are designed to trigger cases that are outside of the reasonable expectations for active treatment, and the cornerstone of this model is outreach and engagement from our behavioral health clinicians to the identified providers for a clinical review. The purpose of the clinical review is to discuss the current treatment plan and to identify and address the appropriate level, intensity and duration of the outpatient treatment needed. The review also provides the opportunity to discuss the availability of additional benefits, the potential need for more intensive treatment or community-based resources, and the benefit of integrated care and/or condition management programs where appropriate.
Psychological/Neuropsychological Testing Program:
The goal of this program is to ensure the member is receiving the medically necessary type and amount of testing. This program involves periodic auditing of providers to determine whether clinical testing practices are in alignment with BCBSIL policies and the member’s benefit plan design. Audits evaluate whether: a) testing meets medical necessity criteria; b) testing is consistent with presenting clinical issues; and c) requested hours for the evaluation meet the established standards of practice and do not vary significantly from the provider’s peer group performing similar services. Providers may be subject to testing prior authorization if the audit concludes the provider’s practice patterns do not align with BCBSIL policies, but that requirement may be waived once the provider has met and maintained alignment with BCBSIL policies for an established period of time. Our Psychological/Neuropsychological Testing Clinical Payment and Coding Policy is available as a reference.
Applied Behavior Analysis (ABA):
ABA is only a covered benefit for Fully Insured plans, Federal Employee Program® (FEP®) plans and Administrative Services Only (ASO) plans. Effective Jan. 1, 2021, BCBSIL removed exclusions and limitations on ABA Therapy for Autism Spectrum Disorder (ASD) and it is now covered as standard claims administration subject to copays, coinsurance and deductible without age, dollar or visit limits. Also, effective Jan. 1, 2021, ASO plans may request to “opt out” of ABA coverage which requires a rigorous review process. ABA will continue to be covered only for Autism Spectrum Disorder (ASD) diagnoses. All providers on behalf of the member are required to notify BCBSIL of a request to provide ABA services for members. The initial prior authorization process will be used to confirm:
- Member has a confirmed autism diagnosis by an appropriate diagnostician;
- Provider is qualified to conduct ABA services;
- Member has benefit coverage for ABA services; and
- The initial treatment plan meets medical necessity.
Refer to the Behavioral Health Prior Authorization Requirements and Process page for details on when and how to submit prior authorization requests.
All behavioral health benefits are subject to the terms and conditions as listed in the member’s benefit plan The Behavioral Health program is available only to those members whose health plans include behavioral health benefits through BCBSIL. Some members may not have outpatient behavioral health management. All behavioral health benefits are subject to the terms and conditions as listed in the member’s benefit plan.
Checking eligibility and/or benefit information and/or obtaining prior authorization is not a guarantee of payment. Benefits will be determined once a claim is received and will be based upon, among other things, the member’s eligibility and the terms of the member’s certificate of coverage, including, but not limited to, exclusions and limitations applicable on the date services were rendered. If you have any questions, call the number on the member’s ID card.
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