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PAP907

Behavioral Health Clinical Review Process


Provider Administrative Policy

Section
Behavioral Health
Policy Date
April 2010
Status/Date
New/April 2010
Provider Type(s)
All Providers  

Disclaimer

Our provider administrative policies contain information regarding claims submission, reimbursement, and other information in order to achieve an efficient relationship with our providers. These policies are not an authorization or explanation of benefits. Blue Cross of Idaho retains the right to add to, delete from and otherwise modify this policy in accordance with our provider contracts.

Policy

Behavioral Health Clinical Review Process

Most Blue Cross of Idaho policies require prior authorization for Mental Health and Substance Abuse for the following levels of care:

  • Inpatient hospitalization
  • Residential treatment
  • Partial hospitalization
  • Intensive outpatient programs
  • Electroconvulsive treatment
  • Psychological and neurological testing
  • Outpatient extended care where there may be a "pass-through" benefit (i.e. a designated number of outpatient sessions that do not require pre-certification under certain benefit plans)

Refer to PAP902

Prior Authorization
We cannot successfully review prior authorization requests to determine medical necessity retrospectively. Our partnership with providers depends on a cooperative effort to review care prospectively.

Providers must notify Blue Cross of Idaho prior to admitting a member to any level of care, with the exception of outpatient care where there may be a "pass-through" benefit (i.e. a designated number of outpatient sessions that do not require  prior authorization under certain benefit plans).

The provider has the option of completing an online initial prior authorization form or calling Blue Cross of Idaho to conduct a telephone review for all levels of care except psychological/neurological testing and outpatient extended care.

For psychological/neurological testing and outpatient extended care the provider can complete the online initial prior authorization form or the paper form and fax it to Blue Cross of Idaho. After we receive all necessary clinical information we will review it for medical necessity and inform the provider of our determination. If a course of treatment is determined to be medically necessary, the authorization will be for a specific period of time and level of care commensurate with the member's clinical condition.

Concurrent Review
Ongoing concurrent treatment reviews are essential to determine the continuing medical
necessity of care. We conduct our concurrent reviews with a clinically focused telephone
discussions between the provider and a Blue Cross of Idaho clinician, through a review of the online concurrent review form or a review of the applicable paper form. The provider has the choice of completing the online concurrent review prior authorization form or of calling Blue Cross of Idaho to conduct a telephonic review for all levels of care except psychological/neurological testing and outpatient extended care requests. For those two levels of care the provider can choose to complete the online concurrent review prior authorization form or the applicable paper form.

If, prior to the end of the prior authorization period or any subsequent authorization, the provider proposes to continue treatment, he or she must complete the online concurrent review prior authorization form, call Blue Cross of  Idaho for a telephonic review or complete the applicable paper form to recertify the level of care based on medical necessity. The case manager conducts the continued stay review with a focus on continued severity of symptoms, appropriateness and intensity of treatment plan, patient progress and discharge planning. This includes reviewing the member's case records and discussing treatment options with the provider or appropriate facility or other behavioral health providers.

We must complete the review process at least 24 hours prior to the end of the current authorization period for all levels of care, except psychological/neurological testing and outpatient extended care which must be requested at least 10 days prior to the end of the current prior authorization period.

Discharge Summary
Discharge planning is an integral part of the treatment process and begins with our initial
review. As a member is transitioned from inpatient levels of care to lower levels of care, the Case Manager will discuss with the provider the patient`s discharge plan.

Please complete the discharge summary and communicate it to the aftercare provider for inpatient level of care as soon as possible to encourage continuity of care for the member. For all other levels of care, you should complete the discharge plan within two weeks of the patient being discharged from care.

The provider has the option of completing the online discharge form or a telephonic review with a Blue Cross of Idaho clinician. If the provider requests a telephonic discharge, he or she must be prepared to report all of the information identified on the Required Member Clinical Information template.

Options for Clinical Review

LEVEL OF CARE

REVIEW TYPE

REVIEW METHOD

 

Inpatient Hospitalization

Prior Authorization

Online prior authorization form or telephonic review

Inpatient Hospitalization

Concurrent

Online concurrent review form or telephonic review

Inpatient Hospitalization

Discharge

Online discharge form or

telephonic review

 

23 Hour Observation

Prior Authorization

Online prior authorization form or telephonic review

23 Hour Observation

Concurrent

Online concurrent review form or telephonic review

23 Hour Observation

Discharge

Online discharge form or

telephonic review

 

Partial Hospitalization

Prior Authorization

Online prior authorization form or telephonic review

Partial Hospitalization

Concurrent

Online concurrent review form or telephonic review

Partial Hospitalization

Discharge

Online discharge form or

telephonic review

 

Intensive Outpatient Program

Prior Authorization

Online prior authorization form or telephonic review

Intensive Outpatient Program

Concurrent

Online concurrent review form or telephonic review

Intensive Outpatient Program

Discharge

Online discharge form or

telephonic review

 

Psychological/Neurological Testing

Prior Authorization

Paper form

Psychological/Neurological Testing

Concurrent

None needed

Psychological/Neurological Testing

Discharge

None needed

 

Outpatient Extended Care

Prior Authorization

Online prior authorization form or

paper form

Outpatient Extended Care

Concurrent

Online concurrent review form or

paper form

Outpatient Extended Care

Discharge

Online discharge form or

telephonic review

Accessing the Online Prior Authorization Forms:
Facilities and providers may submit the appropriate online prior authorization request by following these steps:

*We do not handle requests for psychological/neurological testing, electroconvulsive (ECT) therapy and initial authorizations for Federal Employees Program (FEP) through Web application. Please refer to PAP901 and PAP902.

  1. Access the Web site at bcidaho.com
  2. Select Providers and log in
  3. Select Eligibility & Claims
  4. Select Inpatient Prior Authorization Status or Outpatient Prior Authorization Status depending on the level of care requested, to verify if an authorization has already been established. If the authorization is not showing in the Status screen;
  5. Select Authorization Submission, if there is not a previous authorization then proceed to #6.
  6. Select the appropriate level of care for prior authorization:

Behavioral health outpatient prior authorization

  • Behavioral health intensive outpatient-mental health
  • Substance abuse or dual diagnosis
  • Behavioral health partial hospitalization (facilities ONLY)
  • Behavioral health inpatient (facilities ONLY)
  1. Select prior authorization; concurrent review or discharge summary
  2. Complete the required information on the appropriate form.
  3. Once the form is completed, select Submit to submit the completed prior authorization request form to Blue Cross of Idaho.
  4. Print the confirmation that shows the reference ID. This will be the cover sheet for your fax when you send required medical records. We will also send an email confirmation with the same reference ID indicating Blue Cross of Idaho received the authorization request.
  5. Once Blue Cross of Idaho has authorized the level of care, the provider can check the Inpatient Prior Authorization Status or Outpatient Prior Authorization Status to determine what was authorized.

Telephonic Reviews
If the provider chooses to contact Blue Cross of Idaho for a telephonic review instead of completing the appropriate online prior authorization request form, he or she must be prepared to provide the Blue Cross of Idaho clinical staff the information needed for prior authorization review of the level of care being considered. The following link is a list of the information that may be needed at the time of the telephonic review.

Required Member Clinical Information Form

Please contact the Provider Contact Center or your provider relations representative for details (See PAP100).


Policy History

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