Home > Clinical Resources > Clinical Programs & Information > Mental Health
Web Content Viewer
Authorizations & Medical Necessity

Before performing a service, you should:

Step Check a member’s eligibility and benefits, including authorization requirements.
Use an eTool like ConnectCenter.

The eTool Authorization Manager can be used to verify eligibility but does not provide benefit information.

Step If necessary, request authorization.
For most situations, the fastest way to request authorization is to use Authorization Manager
  • When authorization is required for acute inpatient or acute residential treatment, the facility must call the number on the back of the member’s ID card. Use this number during normal business hours or to register the admission with our after-hours phone service.
  • To fax a request, use a form in our Forms library or Medical Policy library. (Some services and drugs, like Esketamine Nasal Spray, have medical policy forms.)
  • For out-of-network requests, please use the Managed Care Out-of-Network Request Form.
  • You may also request an authorization by calling 1-800-524-4010.

Authorization is not required for psychotherapy, psychiatric office visits, or mobile crisis intervention.

In addition, if a POS member is using their out-of-network benefits, authorization requirements do not apply.

Authorization and medical necessity resources

To Then
  • Check medical necessity criteria
  • Find authorization guidelines for a service (and sometimes service-specific request forms)
Refer to medical policies for Federal Employee Program members and Commercial HMO/POS and PPO members.

For Medicare Advantage members, begin with medical policy 132, Medicare Advantage Management. When there is no applicable Coverage Determination (NCD or LCD*), we follow our commercial medical policies.

  • Read a summary of standard authorization requirements by product and service
Download our Authorization Quick Tip and go to the page titled Mental health authorization notification requirements.
  • Request a clinical exception for coverage
(You can request an exception if your patient's circumstances are unique.)
Read our medical policy document, Clinical Exception Process (Individual Consideration).

* For Medicare Advantage members, we are required to make coverage determinations for services through the CMS National Coverage Determination (NCD) policies and benefit manuals. In addition, we follow Local Coverage Determination (LCD) policies established by the Massachusetts Medicare Administrative Contractors. These policies supersede our commercial medical policies.

Federal Employee Program (FEP) resources
FEP frequently has its own requirements. Detailed benefit descriptions, including exclusions and member copayment information for these services, are available in the Blue Cross and Blue Shield Service Benefit Plan brochures.

Acute care and intermediate services

Expand All
Acute inpatient admissions from an Emergency Department

For most plans, we require notification (not prior authorization) within 72 hours of admission for the initial 72 hours.

The facility must call the number on the back of the member’s ID card to notify us of the admission. If the member does not have their ID card, call 1-800-524-4010.

Federal Employee Program (FEP)

The Federal Employee Program is a unique account with its own terminology. For FEP:
  • “precertification” is the review of inpatient hospital stays to ensure they’re medically necessary before you receive services, and
  • “prior approval” is the review of specific services or prescription drugs to ensure they are medically necessary.

Precertification is required for acute inpatient care. If we don’t receive precertification within 48 hours of the admission, the member will have to pay a $500 penalty. To request precertification:

Note: FEP members with the Basic Option or FEP Blue Focus plan can only use providers who participate in our PPO networks.

Intermediate services

Intermediate services may include acute residential treatment (sub-acute care), partial hospitalization programs, intensive community-based treatments (for children and adolescents), and intensive outpatient programs.

All authorizations for intermediate services are based on the medical necessity of services.

Expand All
Acute residential treatment (sub-acute care)
Plan type Admission type Requirement
Commercial HMO/POS and PPO Mental health Notification within 72 hours of admission.
Commercial HMO/POS and PPO Substance use Notification within 48 hours of admission (for adults) or 72 hours of admission (for children and adolescents 22 years of age or less).
Medicare Advantage Either mental health or substance use Prior authorization is required.
Federal Employee Program Either mental health or substance use Precertification is required, and additional requirements apply. See below.

For FEP members, enrollment in a case management program is required for coverage

The member must be enrolled in case management before the facility can request precertification. To enroll, providers (or members themselves) can refer the member for residential treatment by calling FEP Case Management Program at 1-800-689-7219 ext. 31133.

If a member does not receive precertification before being admitted, benefits will not be covered for their services.

How do I request precertification for FEP?

Facilities should call FEP at 1-800-524-4010 before the admission. You will need to provide:

  • The member’s written consent for participation in case management, and
  • A preliminary treatment and discharge plan.
Partial hospitalizations
  • Authorization is required for Medicare Advantage and Commercial HMO/POS and PPO plans.
  • No precertification is required for FEP.
Intensive community-based treatments (for children and adolescents)
  • When covered, prior authorization is required. Check benefits and eligibility before rendering services.
  • Not a covered benefit for FEP, and not typically a benefit for Medicare Advantage.

 Behavioral Health for Children and Adolescents Fact Sheet (for community mental health centers)

If you have questions, you can call Behavioral Health Clinical Intake at 1-800-524-4010.

Fax numbers are in the “Contact Us” section of our Prior Authorization Overview page.