Reminder: New Administration for Behavioral Health Begins January
As previously announced, effective January 2011, BCBSTX will integrate behavioral health with medical care management. BCBSTX independently licensed behavioral health professionals will manage the program for all non-HMO members, replacing Magellan Health Services.
This update highlights upcoming program changes to help facilitate a smooth transition for you and your patients. (Outpatient care management services and outpatient preauthorization requirements do not apply to those patients/members who do not have outpatient behavioral health benefits with BCBSTX.)
Important Updates and Information
1. Integrated Behavioral Health Model – for overall care management
- Behavioral health care management will be more integrated as part of the Blue Care Connection® (BCC) medical care management program.
- The goal is to support early identification of members who could benefit from co-management of behavioral health and medical conditions.
- This model should result in improved outcomes, enhanced continuity of care, greater clinical efficiencies and reduced costs over time.
2. Services provided by the Behavioral Health program
- Care/Utilization Management for inpatient, outpatient and partial hospitalization
- 24-hour referral assistance
- Condition Management support for behavioral disorders – depression, alcohol/substance abuse, anxiety/panic, bipolar, eating disorders, schizophrenic/other psychotic disorders
- Case Management services for complex needs/issues
- Referrals to other BCC medical care management programs
3. Transition of Care
- BCBSTX will work with you to help limit the possibility for disruptions in patient care coordination during the transition
- During this transition, Magellan Health Services will:
- Continue to authorize covered outpatient services and inpatient admissions for dates of service that begin on or before December 31, 2010.
- Make medical necessity determinations for covered behavioral health services for service dates that begin on or before December 31, 2010.
- Answer questions for care authorized with service dates on or before December 31, 2010.
- Beginning January 1, 2011, members and behavioral health professionals and physicians can contact BCBSTX at the phone number on the back of the member ID card to request preauthorization, submit treatment or continuity of care plans and more.
4. Preauthorization process
- Members must request preauthorization for all covered behavioral health services before treatment.
- You, or a member’s family member, may request preauthorization on the member’s behalf.
- Members beginning treatment and those with treatment ongoing must request preauthorization, regardless of how long the member has been a patient.
- To request preauthorization, call the number on the back of the member ID card.
- All services must be medically necessary, including:
- Inpatient services - acute inpatient treatment, residential treatment centers (RTCs are only applicable for employer groups whose health plans include this coverage option.)
- Outpatient services - intensive outpatient programs, office visits, group therapy
- Partial hospitalization admissions
- Members may be financially responsible for services that are not covered in their plan or that are deemed medically unnecessary.
- Changes to existing preauthorization requirements are not effective until the member’s 2011 group renewal.
5. Failure to preauthorize
- Outpatient - If a member receives outpatient behavioral health visits without requesting preauthorization, a reminder will be sent to the member with their Explanation of Benefits including instructions for how to request preauthorization. The provider will also be notified.
- There will be no benefit reduction for failing to request preauthorization for outpatient treatment. However, BCBSTX may request clinical information to determine medical necessity.
- Inpatient or partial hospitalization admissions – There are no changes to inpatient preauthorization requirements. Members who fail to request preauthorization for inpatient treatment may experience the same benefit reductions that apply for inpatient medical services.
6. Outpatient services – additional information
- Outpatient visits exceeding an initial 10 office visits will require you to submit an Outpatient Treatment Request (OTR) form via phone or fax for a medical necessity review. You may submit at any time before the 11th visit. OTR forms will be posted online at bcbstx.com/provider under Forms by the end of the year.
- Counting outpatient office visits toward the annual 10 visit authorization allowance does not begin until the member’s 2011 group plan renewal.
7. Important telephone and fax numbers, PO Box address (effective January 1, 2011)
- All BCBSTX customer service and other phone numbers as well as service hours will remain the same.
- New Behavioral Health (BH) Unit PO Box Address & Fax Number: Note: PO Box will also be posted on bcbstx.com/provider
Submission of Completed BH Forms:
Blue Cross and Blue Shield of Texas BH Unit
PO Box 660241
Dallas, TX 75266-0241
Fax Number: Toll-free 877-361-7646
Note – Claims Submission Address Remains the Same:
Blue Cross and Blue Shield of Texas
P O Box 660044
Dallas, TX 75266-0044
8. Other important information
- There is no change to the claim submission process.
- There is no change to the BCBSTX provider contract language.
- In January, call the number on the back of the member’s ID card to:
- Request preauthorization
- it treatment plans
- in OTR/Psychological testing forms
- act customer service
- iEXCHANGE, a web-based application that supports an automated preauthorization process for BCBSTX, will be available in 2011. Details and training will be announced at a later date.
- The BCBSTX Provider Manual, other reference materials and forms will be updated and posted on bcbstx.com/provider by January 1, 2011.
More information is available in the updated Frequently Asked Questions (FAQs) posted October 29, 2010, on our website at bcbstx.com/provider. If you have any questions, please contact your professional provider network representative.