Before performing a service, you should take these steps:
|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 benefits information.
|Step||If necessary, request authorization.
For most situations, the fastest way to request authorization is to use Authorization Manager.
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.
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.
||Download our Authorization Quick Tip and go to the page titled Behavioral health authorization notification requirements.|
||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.
For most plans, notification (not prior authorization) within 48 hours of admission is required for the initial 48 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)
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 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.
|Plan type||Admission type||Requirement|
|Commercial HMO/POS and PPO||Mental health||Prior authorization is required.|
|Commercial HMO/POS and PPO||Substance use||Notification within 48 hours of admission.|
|Medicare Advantage||Either mental health or substance use||Prior authorization is required.|
|Federal Employee Program||Either mental health or substance use||Prior authorization 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 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 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:
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.