Behavioral Health Outpatient Management Program
The Blue Cross and Blue Shield of Illinois (BCBSIL) Behavioral Health (BH) Outpatient Management Program includes the management of intensive and some routine outpatient services.
The benefit of the full BH Program – inpatient and outpatient management – is that it allows the BH team to assist members throughout the entire continuum of their BH care and treatment. This structure allows the BH team to follow/monitor 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 Program also allows the BH team to “touch” every member who utilizes BH 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 BH treatment are more likely to experience fewer readmissions and a more positive treatment outcome.
The Program is designed to reduce the administrative burden and improve collaboration and satisfaction with our providers yet ensure members maximize the benefits available to them and avoid claims costs for medically unnecessary care.
Components of Outpatient Management Include
Management of intensive outpatient services:
Intensive outpatient services are managed by preauthorization and concurrent reviews. The pre-authorization allows the opportunity to ensure these intensive services are medically necessary, clinically appropriate and are likely to contribute to a successful treatment outcome. These intensive services are:
- Intensive Outpatient Programs (IOPs)
- 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 preauthorization is required for these testing services).
Management of routine outpatient services:
BH outpatient services also include routine services such as individual, family and/or group psychotherapy as well as psychiatric medication management. These routine services do not require pre-authorization under the BH Outpatient Management Program. These routine services are, however, managed by the Focused Outpatient Management Program portion of our Outpatient Management Program which is described in more detail later in this document.
How does Pre-authorization for Intensive Outpatient Services work?
To determine benefit coverage prior to the service and to determine if preauthorization for intensive outpatient services are required by a specific employer group, members should call the preauthorization MH/SA number listed on the back of their ID card or the BCBSIL BH Call Center at 800-851-7498. This preauthorization requirement only applies for members who have BH Outpatient Management as part of their BH benefit plan through BCBSIL.
Preauthorization for these services requires completion of a form(s) located on the Forms page. Preauthorization requirements for ABA services are outlined below.
BH professionals and physicians, or the member’s family, acting on behalf of the member, may also place the preauthorization call. BCBSIL will comply with all federal and state confidentiality regulations before releasing any information about the member.
Pre-authorization for Applied Behavior Analysis (ABA)
ABA is only a covered benefit for Fully Insured plans, FEP plans or those ASO plans that choose to cover ABA services. ABA will 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 pre-authorization process will be utilized 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.
As part of the initial pre-authorization process, the provider must submit a packet of three (3) ABA forms (Diagnostic Physician/Specialist Evaluation; Provider Credentials Verification; Assessment Info & Initial Treatment Plan) to confirm the above requested information. These forms are available on the BCBSIL Forms page or by calling the BH Call Center at 800-851-7498 (800-779-4602 for FEP only). Once these forms are reviewed, a pre-authorization letter is sent to the member and provider by mail to confirm or decline the service request. Once the initial pre-authorization process has been completed, the provider may initiate ABA services for the member.
During each episode of authorized treatment, the BH 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 Managed Care/Concurrent Review Form and any additional medical records that might be requested by the BH Outpatient team. This form is available on the Forms page or by calling the BH Call Center.
If a claim is submitted without completion of the initial or concurrent preauthorization process, the provider and member will receive a denial notification. The provider will be directed to complete the required preauthorization process and a retroactive review may be required. The provider can contact the BH Outpatient Team at any time for clarification of the process at the BH Call Center number listed above.
How does the Focused Outpatient Management Program for routine services work?
The cornerstone of this model is outreach and engagement from BCBSIL BH clinicians 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.
When a member is identified through the program as potentially benefiting from further review and collaboration, BCBSIL will contact the member’s provider by letter and request additional clinical information about the member’s care and treatment. The provider will be asked to complete an enclosed Clinical Update Request Form and return it to BCBSIL within 30 days of the date of the letter. Clinical information provided will be reviewed by Behavioral Health clinical staff for further recommendations and determination of coverage based on member benefit plans.
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.
In addition to the provider outreach and collaboration described above, BCBSIL will also send a letter to the member to inform him or her that their provider has been asked to provide clinical information to BCBSIL to ensure the member is getting medically necessary and appropriate quality care and treatment. The letter will explain that the member’s current treatment is approved during this 30-day period. If the provider does not submit the requested information within the 30-day timeframe, BCBSIL may not be able to determine if the care and treatment provided is medically necessary or appropriate. As a result, authorization for continued services may be discontinued and the member may be financially responsible.
What should I do if I am contacted about behavioral health services?
Providers will be notified by letter that the member’s routine care and treatment may benefit from further review and collaboration through the Behavioral Health Focused Outpatient Management Program. To assist in this effort, you will be asked to complete a Clinical Update Request Form which will be included in the initial notification. BCBSIL will review the information provided for further recommendations and make a determination of coverage based on member benefit plans. If BCBSIL does not receive this important clinical information within 30 days from the date of the letter, claim reimbursement for applicable services may be denied. If BCBSIL is unable to determine that these services meet the criteria for medical necessity as outlined in the member’s benefit plan, the member may be financially responsible for those services.