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Behavioral Health

Acute inpatient admissions

Medicare Advantage and commercial products (HMO/POS, PPO, EPO, and Indemnity)

Prior authorization is not required for direct admissions from an Emergency Department, but notification within 48 hours of admission is required for the initial 48 hours.

All authorizations for behavioral health inpatient admissions are based on the medical necessity of services.

The facility must call the number on the back of the member’s ID card to notify us of the admission. Use this number during routine business hours or to register the admission with our after-hours phone service.

If the member does not have their ID card, call 1-800-524-4010.

Federal Employee Program (FEP)

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

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.

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Acute residential treatment (sub-acute care)
  • Medicare Advantage: Not a covered benefit.
  • Commercial:
    • Prior authorization (pre-certification) is required for all behavioral health admissions to acute residential treatment (sub-acute care).
    • Notification within 48 hours of admission is required for all substance use disorder admissions to acute residential treatment (sub-acute care).
    • For prior authorization/pre-certification, the facility must call the number on the back of the member’s ID card. Use this number during routine business hours or to register the admission with our after-hours phone service.
  • Federal Employee Program:
    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:

    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 pre-certification. 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 pre-certification before being admitted, benefits will not be covered for their services.

    How do I request pre-certification?
    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 hospitalization programs
  • Medicare Advantage: Prior authorization is required.
  • Commercial: Prior authorization is required.
  • FEP: No pre-certification is required.
Intensive community-based treatments (for children and adolescents)
  • Medicare Advantage: Not typically a benefit for Medicare Advantage. No prior authorization is required.
  • Commercial: When covered, prior authorization is required. Check benefits and eligibility before rendering services.
  • FEP: Not a covered benefit.

 Intensive Community-based Treatment Fact Sheet (for community mental health centers)

Intensive outpatient programs
  • Medicare Advantage: Not a covered benefit.
  • Commercial: Prior authorization is required.
  • FEP: No pre-certification is required.

Outpatient

Commercial and Medicare Advantage requirements by service type

(For the Federal Employee Program, refer to our FEP medical policies or call 1-800-524-4010.)

Reminder: If a POS member is using their out-of-network benefits, authorization requirements do not apply.

  • Psychotherapy and psychiatric office visits. No authorization required. However, for out-of-network requests, please use the Managed Care Out-of-Network Request Form.
    • For Medicare Advantage, only CMS-approved providers are covered.
  • Neuropsychological testing. Authorization required for commercial HMO/POS plans.
    • Prior authorization is not required for neuropsychological testing provided in conjunction with acute inpatient medical or inpatient behavioral health care. Testing at all other levels of care does require prior authorization.
  • Psychological testing. Authorization required for commercial HMO/POS plans.
  • Applied behavior analysis (ABA). When covered, prior authorization is required for commercial plans. Check benefits and eligibility before rendering services. Not a covered service for Medicare Advantage.
  • Transcranial Magnetic Stimulation (TMS). Prior authorization is required for commercial HMO/POS plans.
  • Electroconvulsive therapy (ECT). Prior authorization required for commercial HMO/POS.
  • Genetic testing. Prior authorization required through our vendor, AIM, for most plans and tests.
  • Urine drug testing. No prior authorization required, but benefit limits apply. Refer to medical policy #674, Drug Testing in Pain Management and Substance Use Disorder Treatment, and the Drug Testing payment policy.
  • Methadone. No prior authorization required for commercial plans. Not a covered benefit for Medicare Advantage.

How to request authorization

You can submit your behavioral health prior authorization requests using one of these methods:

  1. Fax us. The referring clinician or the clinician performing the service must complete and return the appropriate form after their initial patient evaluation. Fax the form to 1-800-641-5199.
  2. Call us. You may request an authorization by calling 1-800-524-4010.
  3. Electronically using McKesson’s Clear CoverageTM. Please note this technology is only available to provider types that typically request authorizations for behavioral health services. You can use Clear Coverage() for:
    • Behavioral Health - Level of Care services
    • Repetitive Transcranial Magnetic Stimulation (TMS)
    • Psychological and Neuropsychological Assessment