Behavioral Health Prior Authorization Requirements and Process
This page includes an overview of commercial non-HMO behavioral health prior authorization requirements, as well as how to submit prior authorization requests.
When is prior authorization required?
Member benefits and review requirements/recommendations may vary based on services rendered and individual/group policy elections. It’s critical to check eligibility and benefits first via the Availity® Provider Portal or your preferred web vendor, prior to rendering care and services. In addition to verifying membership/coverage status and other important details, this step returns information on prior authorization requirements and utilization management vendors, if applicable.
For reference purposes, a Commercial Outpatient Behavioral Health Procedure Code List is available on the Support Materials (Commercial) page in the general Utilization Management section. Additional guidelines are below.
Inpatient and Alternative Levels of Care
Prior authorization is required for all inpatient, residential treatment center (RTC) and partial hospitalization admissions.
- Elective or non-emergency hospital admissions must be preauthorized prior to admission or within two business days of an emergency admission.
- To determine eligibility and benefit coverage prior to service and to determine if RTC services are covered by a specific employer group, members or behavioral health professionals and physicians may call the Behavioral Health number on the member’s Blue Cross and Blue Shield of Illinois (BCBSIL) ID card.
Intensive Outpatient Services
This requirement applies only for members who have outpatient management as part of their behavioral health benefit plan through BCBSIL. These intensive outpatient services require prior authorization to confirm that the services are medically necessary, clinically appropriate and contribute to the successful outcome of treatment:
- Intensive Outpatient Programs (IOP)
- Partial Hospital Program (PHP)
- 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 prior authorization is required for these testing services).
To determine benefit coverage prior to the service and to determine if prior authorization for intensive outpatient services may be required by a specific employer group, members may call the prior authorization MH/SA number listed on their ID card or the BCBSIL Behavioral Health Call Center at 800-851-7498. This prior authorization requirement only applies for members who have Behavioral Health Outpatient Management as part of their behavioral health benefit plan through BCBSIL.
Additionally, Federal Employee Program® (FEP®) members must request prior authorization for ABA services but are not required to request prior authorization for PHP or any other outpatient behavioral health services.
For prior authorization requirements summaries and procedure code lists for Medicare Advantage PPO and Illinois Medicaid members, refer to the Support Materials (Government Programs) page.
What’s the process for submitting prior authorization requests?
Members are responsible for requesting prior authorization when prior authorization is required. Behavioral health providers or a member’s family member may request prior authorization on behalf of the member. BCBSIL will comply with all federal and state confidentiality regulations before releasing any information about the member. All services must be medically necessary.
Inpatient and Alternative Levels of Care – Members should call the appropriate number on the their BCBSIL ID card.
Outpatient – Members should call the behavioral health number on their BCBSIL ID card. For these outpatient services, prior authorization requires completion of a form located on the Forms page.
Intensive Outpatient Programs (IOPs), Outpatient ECT or rTMS
Prior authorization for these services requires completion of a form or forms, as listed on the Forms page. Once the completed forms are reviewed a letter is sent to the member and provider by mail to confirm or decline the service request.
Additionally, providers may use the Availity Authorizations tool to submit electronic prior authorization requests for inpatient admissions and select outpatient services that require prior authorization through BCBSIL. Refer to the Provider Tools section for more information, including an Availity Authorizations User Guide .
Applied Behavior Analysis (ABA)
As part of the initial prior authorization process, the provider must complete and submit the appropriate ABA form to confirm the requested information. The forms are available on the Forms page or by calling the BCBSIL Behavioral Health Unit. Once these forms are reviewed a letter is sent to the member and provider by mail to confirm or decline the service request. Once the initial prior authorization has been approved, the provider may initiate ABA services for the member.
During each episode of authorized treatment, the Behavioral Health Outpatient Management team may outreach to the provider to participate in the concurrent review process. If contacted, the provider is required to provide clinical justification for continued treatment through submission of the ABA Clinical Service Request Form and any additional medical records that might be requested
If a claim is submitted without completion of the initial or concurrent prior authorization process, the provider and member will receive a denial notification. The provider will be directed to complete the required prior authorization process and a retroactive review may be required. The provider may contact the Behavioral Health Outpatient Team at any time for clarification of the process at the Behavioral Health Call Center number listed above. Our Applied Behavior Analysis Clinical Payment and Coding Policy is available as a reference.
What happens if a required prior authorization isn’t obtained?
For Inpatient and Alternative Levels of Care, members who do not request prior authorization for inpatient and alternative levels of care behavioral health treatment may experience the same benefit reductions that apply to medical services. Medically unnecessary claims will not be reimbursed.
For Outpatient services, if a member receives any of the behavioral health services listed below without prior authorization, BCBSIL will request clinical information from the provider for a medical necessity review. The member will also receive notification.
- Psychological and Neuropsychological Testing (if applicable)
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.
Availity is a trademark of Availity, LLC, a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to BCBSIL. BCBSIL makes no endorsement, representations or warranties regarding any products or services provided by third party vendors such as Availity. If you have any questions about the products or services provided by such vendors, you should contact the vendor(s) directly.