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Clarification: Updates to Behavioral Health Claim Review Process

Posted June 24, 2019

Our May Blue Review included an article titled, ‘Check Your Patients' Behavioral Health Benefit Preauthorization Requirements’; this article also was posted April 30, 2019, in the News and Updates. The following article includes an updated effective date and other details to provide clarification to the previously published information.

Beginning Aug. 26, 2019,* we are updating our internal review process for behavioral health claims that require benefit preauthorization. Please note that only the claim review process is being updated. The specific services requiring benefit preauthorization and the process for submitting benefit preauthorization requests are not changing.

You may be asking how this impacts you. We need your help to ensure claims are billed properly. Please remember, for all claims:

  • Check eligibility and benefits for each patient prior to rendering services. This will help you determine if benefit preauthorization is required.
  • Receive any required benefit preauthorization before care is rendered.
  • Bill industry standard codes to help expedite claim payment and support satisfactory customer service for your patients, our members.

In April, we told you that claims without the appropriate preauthorization will be denied for payment. We want to clarify that statement. Billing treatment for our members without the required benefit preauthorization may delay payment of your claim. If delayed, you will have an opportunity to submit medical records for further review.

For more information on behavioral health benefit preauthorization requirements, visit the Behavioral Health Program section of our Provider website.

The updated claim review process referenced above does not affect claims submitted for HMO, government programs, or Federal Employee Program® (FEP®) members.

*The original effective date published in the May Blue Review and April News and Updates was July 15, 2019.

Checking eligibility and/or benefit information and/or the fact that a service has been preauthorized 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 applicable on the date services were rendered. If you have any questions, please call the number on the member’s ID card.