Focused Out-Patient Management

The Blue Cross and Blue Shield of Montana (BCBSMT) Behavioral Health (BH) Outpatient Management Program includes the management of intensive and some routine outpatient services.

The benefit of the full BH Program – inpatient and outpatient management – is that it allows the BH team to assist members throughout the entire continuum of their BH care and treatment. This structure allows the BH 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 Program also allows the BH team to "touch" every member who utilizes BH 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 BH treatment are more likely to experience fewer readmissions and a more positive treatment outcome.

The Program is designed to reduce the administrative burden and improve collaboration and satisfaction with our providers yet ensure members maximize the benefits available to them and avoid claims costs for medically unnecessary care.

BH Outpatient Management includes:

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. These intensive services are:

  • Intensive Outpatient Programs (IOPs)
  • Applied Behavior Analysis (ABA)
  • Outpatient Electroconvulsive Therapy (ECT)
  • Repetitive Transcranial Magnetic Stimulation (rTMS)
  • Psychological and Neuropsychological Testing in some cases (BCBSMT will notify the provider if prior authorization is required for these testing services).

To determine benefit coverage prior to the service and to determine if prior authorization for intensive outpatient services is required by a specific employer group, members should call the prior authorization MH/SA number listed on the back of their ID card or the BCBSMT BH Call Center at 855-313-8909. This prior authorization requirement only applies for members who have BH Outpatient Management as part of their BH benefit plan through BCBSMT.

BH professionals and physicians, or the member's family, acting on behalf of the member, may also place the prior authorization call. BCBSMT will comply with all federal and state confidentiality regulations before releasing any information about the member.

Prior Authorization for Intensive Outpatient Programs, Outpatient ECT or rTMS

Prior Authorization for these services requires completion of a form(s) located at bcbsmt.com/provider. Once these forms are reviewed a letter is sent to the member and provider by mail to confirm or decline the service request.

https://www.bcbsmt.com/provider/education-and-reference/forms-and-documents

Prior authorization for Applied Behavior Analysis (ABA):

ABA is only a covered benefit for Fully Insured plans, FEP plans or those ASO plans that choose to cover ABA services. ABA will be covered only for Autism Spectrum Disorder (ASD) diagnoses.

All providers on behalf of the member are required to notify BCBSMT of a request to provide ABA services for members. The initial prior authorization process will be utilized to confirm:

  • Member has a confirmed autism diagnosis by an appropriate diagnostician;
  • Provider is qualified to conduct ABA services;
  • Member has benefit coverage for ABA services, and
  • The initial treatment plan meets medical necessity

As part of the initial prior authorization process, the provider must complete and submit ABA forms Applied Behavior Analysis (ABA) Clinical Service Request Form and Applied Behavior Analysis (ABA) Initial Assessment Request Form  to confirm the above requested information. These forms are available on the BCBSMT website or by calling the BH Call Center at 855-313-8909 (877-885-3751 for FEP only). Once these forms are reviewed, a prior authorization letter is sent to the member and provider by mail to confirm or decline the service request. Once the initial prior authorization process has been completed, the provider may initiate ABA services for the member.

During each episode of authorized treatment, the BH Outpatient Management team may outreach to the provider to participate in the concurrent review process. If contacted, the provider is required to provide clinical justification for continued treatment through submission of the ABA Clinical Service Request Form and any additional medical records that might be requested.

If a claim is submitted without completion of the initial or concurrent prior authorization process, the provider and member will receive a denial notification. The provider will be directed to complete the required prior authorization process and a retroactive review may be required. The provider can contact the BH Outpatient Team at any time for clarification of the process at the BH Call Center. Our Applied Behavior Analysis Clinical Payment and Coding Policy is available as a reference on our Provider website.

https://www.bcbsmt.com/provider/standards-and-requirements/cpcp

Management of routine outpatient services

BH outpatient services also include routine services such as individual, family and/or group psychotherapy as well as psychiatric medication management. These routine services do not require prior authorization under the BH Outpatient Management Program. These routine services are, however, managed by the Focused Outpatient Management Program portion of our Outpatient Management Program which is described in more detail later in this document.

Focused Outpatient Management Program

This program is a claims-based approach to behavioral health care outpatient management, developed 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 BH 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 BCBSMT Policies and the member’s benefit plan design. Audits evaluate whether: a) testing meets medical necessity criteria, b) testing is consistent with presenting clinical issues and c) 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 BCBSMT policies, but that requirement may be waived once the provider has met and maintained alignment with BCBSMT policies for an established period of time. Our Psychological/Neuropsychological Testing Clinical Payment and Coding Policy is available as a reference on our Provider website.

https://www.bcbsmt.com/provider/standards-and-requirements/cpcp