Behavioral Health Care Management Program
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 preauthorization for Applied Behavior Analysis (ABA) services but are not required to request preauthorization 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 Blue Care Connection® (BCC) 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 BCC 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.
Health Care Service Corporation, Inc. (operating through its five divisions; BCBS of Illinois, BCBS of Montana, BCBS of New Mexico, BCBS of Oklahoma, and BCBS of Texas) Behavioral Health Care Management program has been accredited for Health Utilization Management since October of 2012. This accreditation covers the Behavioral Health Utilization Management program for Commercial/Group, FEP and Retail Exchange Affected Markets lines of business for all five plan states.
URAC, an independent, nonprofit organization, is well-known as a leader in promoting health care quality through its accreditation and certification programs. URAC offers a wide range of quality benchmarking programs and services that keep pace with the rapid changes in the health care system, and provide a symbol of excellence for organizations to validate their commitment to quality and accountability. Through its broad-based governance structure and an inclusive standards development process, URAC strives to ensure that all stakeholders are represented in establishing meaningful quality measures for the entire health care industry. For more information, visit www.urac.org .
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, partial hospitalization, residential treatment center services, and some outpatient behavioral health care 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 the following chronic mental health and substance abuse conditions:
- Alcohol and Substance Abuse Disorders
- Anxiety and Panic Disorders
- Bipolar Disorders
- Eating Disorders
- Schizophrenia and other Psychotic Disorders
- 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 outreach to higher risk members who often have complex psychosocial needs impacting their discharge plan.
- Patient Safety Program (PSP) provides outreach calls to members who may have the potential of becoming higher risk for readmission(s) and/or frequent Emergency Room visits. The goal of the outreach is to provide resources and/or to ensure they have access to the treatment they need.
- Specialty Programs
- Eating Disorder Care Team is a dedicated 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 Care Response 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.
- Referrals to other BCC medical care management programs, and wellness and prevention campaigns.
Members are responsible for requesting preauthorization when preauthorization is required. Behavioral health professionals and physicians or a member's family member may request preauthorization on behalf of the member. All services must be medically necessary according to criteria within standardized guidelines and medical policy. Participating providers are required to notify the plan of all admissions.
Inpatient and Alternative Levels of Care
Preauthorization 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.
Residential Treatment Center (RTC) benefits are generally excluded from most plans; however, there are some employer groups who have elected to cover this service. To determine if RTC services are covered, call the appropriate number on the back of the member's ID card.
These intensive outpatient services require preauthorization prior to the initiation of service 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 preauthorization 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 preauthorization for Applied Behavior Analysis (ABA) services but are not required to request preauthorization for any other outpatient behavioral health services including Partial Hospitalization Programs.
Members are responsible for requesting preauthorization when preauthorization is required, although behavioral health professionals and physicians or a member's family member may request preauthorization 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 with in 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.
- For the services listed above that may require preauthorization, members should call the behavioral health number on the back of their ID card to request preauthorization.
- Behavioral health providers, physicians or a member's family member may request preauthorization on behalf of the member.
- Preauthorization for outpatient services requires completion of a form(s) located at bcbsmt.com/provider.
- Preauthorization requirements for ABA services are outlined in the Behavioral Health Outpatient Management Program located in the Related Resources section of this website.
Failure to Preauthorize
Inpatient, Alternative and Outpatient Levels of Care
For members who do not request preauthorization 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.
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
- Urgent: Within 24 hours
- Routine: Within 10 calendar days
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.
- 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:
- Continuation of care for 12 weeks of continuous treatment (during acute phase)
- Continuation of care 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 2 visits 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:
- Treatment initiation through an inpatient admission, outpatient visit, intensive outpatient encounter or partial hospitalization program within 14 days following the diagnosis (initiation phase)
- At least 2 visits/services, in addition to the treatment initiation encounter, within 30 days of 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.
Preauthorization: Call 855-313-8909 or the number listed on the back of the member ID card.
Submit completed Behavioral Health Forms to:
Blue Cross and Blue Shield of Texas Behavioral Health Unit
Blue Cross Blue Shield of Montana
PO Box 4669
Helena, MT 59604
Fax Number: 855-649-9681
Paper Claims Submission Address:
Blue Cross and Blue Shield of Montana
PO Box 7982
Helena, MT 59604-7982
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, call Health Care Services at 800-447-7828 (toll free) or 800-437-5000 (local), Extension 6100, or email HCS-X6100@bcbsmt.com.
* Members experiencing inpatient hospitalization, complex or special health care needs or who are at risk for medical complications may be referred to BCC programs through a variety of mechanisms such as predictive modeling, claim utilization, inbound calls, self-referrals and physician referrals. If members do not have BCC as part of their group health plans, they will not be referred to other BCC programs.