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 Texas (BCBSTX). 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).
To determine benefit coverage prior to the service and to determine if prior authorization for these intensive outpatient services are required by a specific employer group, members or providers should call the prior authorization MH/SUD number listed on the back of their ID card or the BCBSTX BH Call Center at 1-800-528-7264. Prior authorization for these services requires completion of a form(s) located on bcbstx.com/provider.
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 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 BCBSTX policies and the member’s benefit plan design. Audits evaluate whether:
- testing meets medical necessity criteria;
- testing is consistent with presenting clinical issues; and
- 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 BCBSTX policies, but that requirement may be waived once the provider has met and maintained alignment with BCBSTX policies for an established period of time. Our Psychological/Neuropsychological Testing Clinical Payment and Coding Policy is available as a reference on the Clinical Payment and Coding Policy page.
Refer to the Medical Necessity Criteria & Prior Authorization for Behavioral Health Services page for details on when and how to submit prior authorization requests.
What should I do if I am contacted about behavioral health services?
Providers will be notified by letter if additional information is needed or if a case has been selected for further review and collaboration. To assist in this effort, you may be asked to complete a Clinical Update Request Form which will be included in the initial notification or asked to complete the form(s) which were previously submitted incompletely. BCBSTX will review the information provided for further recommendations and determination of coverage based on member benefit plans. If BCBSTX 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 BCBSTX 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.
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 BCBSTX. 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 BCBSTX. BCBSTX makes no endorsement, representations or warranties regarding any products or services provided by third party vendors such as Availity.