Behavioral Health Programs

Behavioral Health Care Management Program

Blue Cross Blue Shield of Montana (BCBSMT) manages behavioral health services for all members who have behavioral health benefits through a variety of group, government and retail products. Similar behavioral health programs are implemented across product lines but may be modified or enhanced dependent upon the product.

Federal Employees Program (FEP) members are managed by BCBSMT. FEP members must request prior authorization for Applied Behavior Analysis (ABA) services and FEP recommends members request an advanced benefit determination (or predetermination) for Repetitive Transcranial Magnetic Stimulation (rTMS). FEP members are not required to request prior authorization or a predetermination for any other outpatient behavioral health services including Partial Hospitalization Programs.

Behavioral health care management is integrated with our medical care management program as part of Well Being Management® (WBM) to help members access their behavioral health benefits and to improve coordination of care between medical and behavioral health providers.

This program will help BCBSMT 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 WBM 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.

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

Accreditation

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 our health plans, covering all our members.

About NCQA

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.

Behavioral Health Program Components

The BCBSMT Behavioral Health Program encompasses a portfolio of resources that help BCBSMT member's access benefits for behavioral health (mental health and substance use disorder) conditions as part of an overall care management program. It also allows clinical staff to assist in the early identification of members who could benefit from co-management of behavioral health and medical conditions.

Behavioral Health Program components:

  • Care/Utilization Management

    • Inpatient Management for inpatient acute, partial hospitalization, and residential treatment center services.
    • Outpatient Management for members who have outpatient management as part of their behavioral health benefit plan through BCBSMT. The BH Outpatient Program includes management of intensive and some routine outpatient services.

  • Case Management Programs

    • Intensive Case Management provides intensive levels of intervention for members experiencing a high severity of symptoms
    • Condition Case Management provides a comprehensive, integrated approach to the coordination of care for members with chronic mental health and substance abuse conditions, for example:

      • Depression
      • Alcohol and Substance Abuse Disorders
      • Anxiety and Panic Disorders
      • Bipolar Disorders
      • Eating Disorders
      • Schizophrenia and other Psychotic Disorder
      • Attention Deficit and Hyperactivity Disorder (ADD/ADHD)
         
  • Active Specialty Management (ASM) program for members who do not meet the criteria for Intensive or Condition Case Management but who have behavioral health needs and could benefit from extra support or services.
  • Care Coordination Early InterventionSM (CCEI) Program provides post-discharge outreach to higher risk members who often have complex psychosocial needs impacting their discharge plan.
  • Specialty Programs

    • Eating Disorder Care Team is an internal multi-disciplinary clinical team with expertise in the treatment of eating disorders. The team includes partnerships with eating disorder experts and treatment facilities as well as internal algorithms to identify and refer members to appropriate programs.
    • Autism Response Team is also an internal, multi-disciplinary team whose focus is to provide expertise and support to families in planning the best course of Autism Spectrum Disorder (ASD) treatment for their family, including how to maximize their covered benefits.
    • Risk Identification and Outreach (RIO) is our industry-leading model for leveraging robust data analytics to optimize solutions for complex healthcare priorities. This multi-disciplinary collaboration between Behavioral Health (BH), Medical, Pharmacy and Clinical Data Technology groups is focused on mining, organizing and visualizing clinically actionable data for at-risk member populations and implementing clinically appropriate and effective interventions at both member and provider levels.
  • Referrals to other WBM medical care management programs, and wellness and prevention campaigns

Prior Authorization Requirements

Prior authorization (also called precertification or pre-notification) is the process of determining medical appropriateness of the behavioral health professionals and physician’s plan of treatment by contacting BCBSMT for approval of services.

Approval of services after prior authorization is not a guarantee of payment of benefits. Payment of benefits is subject to several factors, including, but not limited to, eligibility at the time of service, payment of premiums/contributions, amounts allowable for services, supporting medical documentation, and other terms, conditions, limitations and exclusions set forth in the member’s policy certificate and/or benefits booklet and/or summary plan description as well as any preexisting conditions waiting period, if any.

As always, all services must be determined to be medically necessary as outlined in the member’s benefit booklet. Services determined not to be medically necessary will not be covered.

For reference purposes, a Behavioral Health Prior Authorization Code List is available on the Prior Authorization lists page.

Inpatient and Alternative Levels of Care

Prior authorization is required for all inpatient, residential treatment center (RTC) and partial hospitalization admissions.

  • Elective or non-emergency hospital admissions must be preauthorized prior to admission or within 24 hours of the admission or next business day of an emergency admission
  • To determine eligibility and benefit coverage prior to service and to determine if RTC services are covered by a specific employer group, members, behavioral health professionals and physicians may call the Behavioral Health number that is listed on the back of the member’s ID card.

Outpatient

The outpatient program requires prior authorization for the following intensive outpatient behavioral health services prior to initiation of service for most plans. Prior authorization for these more intensive services is required to determine that the services are medically necessary, clinically appropriate and contribute to the successful outcome of treatment.

  • Intensive Outpatient Program (IOP)
  • Applied Behavior Analysis (ABA)
  • Outpatient Electroconvulsive therapy (ECT)
  • Repetitive Transcranial Magnetic Stimulation (rTMS)
  • Psychological and Neuropsychological testing in some cases; BCBSMT would notify the provider if prior authorization is required for these testing services.

This requirement applies only for members who have BH Outpatient Management as part of their BH benefit plan through BCBSMT.

FEP members must request prior authorization for Applied Behavior Analysis (ABA) services and FEP recommends members request an advanced benefit determination (or predetermination) for Repetitive Transcranial Magnetic Stimulation (rTMS). FEP members are not required to request prior authorization or a predetermination for any other outpatient behavioral health services including Partial Hospitalization Programs.

Prior Authorization Process

Members are responsible for requesting prior authorization when prior authorization is required, although behavioral health professionals and physicians or a member's family member may request prior authorization on behalf of the member. BCBSMT will comply with all federal and state confidentiality regulations before releasing any information about the member. All services must be medically necessary according to specific criteria within standardized guidelines and medical policy. Participating providers are required to notify the plan of all admissions.

Members are responsible for requesting prior authorization when prior authorization is required, although behavioral health professionals and physicians or a member's family member may request prior authorization on behalf of the member. BCBSMT will comply with all federal and state confidentiality regulations before releasing any information about the member. All services must be medically necessary according to specific criteria within standardized guidelines and medical policy. Participating providers are required to notify the plan of all admissions.

  • Inpatient and Alternative Levels of Care

    • Call the appropriate number on the back of the member's ID card.
       
  • Outpatient

    • Use BlueApprovRSM to request prior authorization for some Behavioral Health services (visit our BlueApprovR Provider Tools Page for instructions)
    • For the services listed above that may require prior authorization, providers can request prior authorization online using Availity Authorization & Referrals for care managed by BCBSMT or members and providers can call the appropriate number on the back of the member’s ID card.
    • Prior authorization for outpatient services requires completion of form(s) located at bcbsmt.com/provider under Education and Reference/Forms and Documents.
    • Automated submission of documents is available for some behavioral health services. Please consult the Claims & Eligibility/Electronic Commerce section of the Montana provider website: bcbsmt.com/provider. 
    • Prior authorization requirements for ABA services are outlined in the document Management of Applied Behavior Analysis located in the Related Resources section under Clinical Resources/Behavioral Health on the provider website.
    • Once a prior authorization determination is made for services requiring prior authorization, the member and the behavioral health professional or physician will be notified of the authorization, regardless of who initiated the request.

Failure to Prior Authorize

Inpatient, Alternative and Outpatient Levels of Care

When prior authorization is not requested for inpatient, alternative levels of care, and the outpatient services previously addressed, BCBSMT will request clinical information from the provider for a retrospective medical necessity review. Claims for services not approved as medically necessary will be denied and are the responsibility of the in network provider. Claims for services not approved as medically necessary by an out of network provider will be the responsibility of the member.

Quality Indicators

Access & Availability Standards

Participating providers treat BCBSMT members as they would any other patient and have agreed to cooperate in monitoring accessibility of care for members, including scheduling of appointments and waiting times. Participating providers must meet the following appointment standards:

  • Emergency: Services must be made available and accessible at all times (24-hour availability with qualified on-call coverage) for life threatening and non-life threatening emergencies
  • Non-life-threatening emergency: Within six (6) hours or Refer to ER
  • Urgent: Within 24 hours
  • Routine: Within 10 calendar days

Behavioral Health Appointment Access Standards

Behavioral Health providers have contractually agreed to offer appointments to our members according to the following appointment access standards:

  • Initial Visit for Routine Care: Within 10 working days
  • Follow-up for Routine Care: Within 30 calendar days
  • Urgent: Within 48 hours
  • Non-life threatening emergency: Within six (6) hours
  • Life threatening/emergency: Within one (1) hour

BCBSMT is accountable for performance on national measures, like the Health Effectiveness Data Information Sets (HEDIS). Several of these measures specify expected timeframes for appointments with a BH professional. View tips for HEDIS.

  • Expectation that a member has a follow up appointment with a BH professional following a mental health inpatient admission within 7 and 30 days.

  • For members treated with Antidepressant Medication:
    • Medication Adherence for 12 weeks of continuous treatment (during Acute phase)
    • Medication Adherence for 180 days (Continuation phase)
  • For children (6–12 years old) who are prescribed ADHD Medication:
    •  One follow up visit the first 30 days after medication dispensed (Initiation phase)
    • At least two (2) visits, in addition to the visit in the initiation phase with provider in the first 270 days after Initiation phase ends (Continuation and Maintenance phase)
  • For members treated with a new diagnosis of alcohol or drug dependence (AOD):
    • Treatment initiation through an inpatient admission, outpatient visit, intensive outpatient encounter, partial hospitalization program, telehealth or medication treatment within 14 days following the diagnosis (initiation phase). 
    • At least 2 visits/services, in addition to the treatment initiation encounter, within 34 days of initiation visit (engagement phase) initial diagnosis (encounter phase)

Continuity and Coordination of Care

Continuity and coordination of care are important elements of care and as such are monitored through the BCBSMT Quality Improvement Program. Opportunities for improvement are selected across the delivery system, including settings, transitions in care, patient safety, and coordination between medical and behavioral health care. Communication and coordination of care among all Professional Providers participating in a subscriber's health care are essential to facilitating quality and continuity of care. When the subscriber has signed an authorization to disclose information to a Primary Care Physician (PCP), the behavioral health provider should notify the PCP of the initiation and progress of behavioral health services.

Contact Information

Prior authorization: Call 855-313-8909 or the number listed on the back of the member ID card.

Submit completed Behavioral Health Forms to:

Blue Cross Blue Shield of Montana
PO Box 660240
Dallas, TX 75266-0240

Fax Number: 855-649-9681
Toll-free: 855-313-8909
Fax: 312-565-2308

Paper Claims Submission Address:

Blue Cross and Blue Shield of Montana
PO Box 660255
Dallas, TX 75266-0255

Additional Information

For routine benefits, eligibility, and claim questions, call Customer Service at 800-447-7828, from 8 a.m. to 5 p.m. MT, M–F.

For new provider contracts and general provider contract questions, BCBSMT provider ID number and NPI questions, credentialing and re-credentialing status, provider roundtable meetings, and complex claims issues beyond the scope of Customer Service, Contact BCBSMT Network Management.

Related Resources: