Behavioral Health Care Management Program

Administration of Behavioral Health Programs

Blue Cross and Blue Shield of Texas (BCBSTX) administers behavioral health services (mental health and substance use disorder) for members who have behavioral health benefits through a variety of retail, government and group products.

The following plans are administered by BCBSTX Behavioral Health Care Management:

  • Blue Choice PPOSM
  • Blue Cross Medicare Advantage PPOSM
  • Blue Cross Medicare Advantage HMOSM effective 01/01/2024
  • Blue Cross Medicare Advantage Dual Care (HMO  SNP)SM effective 01/01/2024
  • Blue EssentialsSM
  • Blue High Performance Network® (BlueHPN®)
  • Blue PremierSM and Blue Premier AccessSM.
  • Employees Retirement System of Texas (ERS)
  • Federal Employee Program (FEPSM)
  • Teacher Retirement System of Texas (TRS)

The following plans are administered by Magellan Healthcare® (Magellan) for behavioral health services:

  • Blue Advantage HMOSM, Blue Advantage PlusSM HMO
  • MyBlue HealthSM
  • Medicaid STAR, CHIP and STAR Kids.(Note: Care Management is managed by BCBSTX as of 06/27/22. Refer to Medicaid Behavioral Health for more information)

In addition, some groups may select other vendors to administer their behavioral health services. For that reason, it is imperative to use Availity® or your preferred vendor to obtain eligibility and benefits, determine who is responsible for administering behavioral health benefits and prior authorization requirements.

Behavioral Health Program Overview

BCBSTX’s behavioral health care management is integrated with our medical care management program, to help members access their behavioral health benefits and to improve coordination of care between medical and behavioral health providers. This program will help our clinical staff identify members who could benefit from co-management earlier and may result in:

  • Improved outcomes
  • Enhanced continuity of care
  • Greater clinical efficiencies
  • Reduced costs over time

Some members* may be referred to other medical care management programs that are designed to help identify and help close potential gaps in care through evidence-based and member-focused approaches to health care and benefit decisions.

All behavioral health benefits are subject to the terms and conditions as listed in the member's benefit plan.

Behavioral Health Program Components

Our program includes a portfolio of resources to help our members access benefits for behavioral health (mental health and substance abuse) conditions as part of an overall care management program. Learn more

Behavioral Health Utilization Management Program Overview

Our Behavioral Health team follows members as they step down from intensive inpatient, residential or partial hospitalization to less intensive levels of care (outpatient). Learn more

Behavioral Health Medical Necessity Criteria & Prior Authorizations

The BCBSTX Behavioral Health team uses nationally recognized, evidence-based and/or state or federally mandated clinical review criteria and issue prior authorizations for all behavioral health clinical decisions. Learn more

Behavioral Health Quality Indicators

Behavioral Health providers have contractually agreed to offer appointments to our members according to specific appointment access standards. Learn more

Behavioral Health Contacts & Additional Information

Questions? We’re here to help. Learn more

Accreditations

NCQA

Our Behavioral Health Care Management program is accredited for Health Utilization Management through the National Committee for Quality Assurance (NCQA). The accreditation is for all of our health plans, covering all our members. 

NCQA is a private, nonprofit organization dedicated to improving health care quality. NCQA accredits and certifies a wide range of health care organizations. It also recognizes clinicians and practices in key areas of performance. NCQA’s Healthcare Effectiveness Data and Information Set (HEDIS®) is the most widely used performance measurement tool in health care. NCQA’s website contains information to help consumers, employers and others make more informed health care choices.

* Members experiencing inpatient hospitalization, complex or special health care needs or who are at risk for medical complications may be referred to medical care management programs through a variety of mechanisms such as predictive modeling, claim utilization, inbound calls, self-referrals and physician referrals. If members do not have medical care management programs as part of their group health plans, they will not be referred to other medical care management programs.

Availity is a trademark of Availity, L.L.C., a separate ‭company that operates a health information network to ‭provide electronic information exchange services to ‭medical professionals. Availity provides administrative ‭services to BCBS‬‬‬‬TX. BCBSTX makes no endorsement, ‭representations or warranties regarding any products or ‭services offered by independent third-party vendors such ‭as Availity. If you have any questions about the products ‭or services offered by such vendors, you should contact ‭the vendor(s) directly.‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬

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