Before performing a service, you should:
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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.
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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 |
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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. |
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Download our Authorization Quick Tip and go to the page titled Mental health authorization notification requirements. |
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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
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.
- “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:
- Call 1-800-524-4010.
- Fax the Behavioral Health - Level of Care Request Form to us at the number listed on the cover sheet.
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 | 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. |
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.
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.
- Authorization is required for Medicare Advantage and Commercial HMO/POS and PPO plans.
- No precertification is required for FEP.
- 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.
To expand access to care for our members, we have complemented our existing network of mental health clinicians by adding mental health groups that offer therapy, medication management, and specialty care to address specific conditions. Many of these mental health groups have:
- In-person and telehealth appointments
- A central intake system for matching and scheduling appointments
- A robust directory of varied provider types
Here’s how to help your patients find care
Need help directing your patients to the right mental health care quickly and efficiently? We encourage you to point them to our MyBlue Mental Health Options page. It’s a tool that streamlines the process of finding a mental health provider for your patients.
Please share this fact sheet and the below simple steps with your patient:
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Sign into your MyBlue account and click on My Care>Mental Health Options. |
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Optional: Answer a brief set of 4-5 questions to assess your specific mental health needs. It can be retaken if needed. |
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Scroll down to see a list of recommended providers. A separate Results for You category will appear only you if answered the optional 4-5 questions mentioned above. |
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Click on Get Started with any of the groups that you think will be a good fit for your mental health needs. You’ll be brought to their websites where you can learn more and easily schedule an appointment. |
Mental health groups
Below is a list of the mental health provider groups your patients will see as options on our site. Click each category to learn more.
If your patient could benefit from a collaborative approach, combining mental health and primary care, then Firefly Health and Carbon Health might be the solution. Both are national provider groups that offer virtual primary and mental health care to our members. Eligible members* can choose a virtual primary care provider associated with either group and get support from a virtual care team to manage their health. Both Firefly and Carbon work closely with mental health providers to give members a collaborative care experience.
*Firefly Health and Carbon Health are currently available to our members with commercial plans (HMO, PPO, and POS). These options will be available to Medicare Advantage and Federal Employee Plan members in the future.
The following groups offer mental health care in-person and virtually, as described below. The clinicians are generalists who provide therapy and medication management. They have an easy-to-use central intake service where members can log on and schedule appointments. These groups strive to schedule our members for their first appointment in a two- to three-day timeframe from the initial call.
| Name | Patient ages accepted | Virtual options offered? | In-person visits offered? |
|---|---|---|---|
| Alma | 5 years and up | Yes | Dependent on each individual clinician |
| Headway | 6 years and up | Yes | Yes |
| Refresh Mental Health | 4 years and up | Yes | Yes |
| Talkiatry | 6 years and up | Yes | No |
| Thriveworks |
6 years and up for therapy
14 years and up for medication management |
Yes | Yes |
| Valera Health | 6 years and up | Yes | Yes |
The following groups offer innovative clinical care among a variety of specialized mental health conditions. Often, these subspecialty groups provide alternatives to residential treatment.
| Name | Areas of focus | Patient ages accepted | Virtual options offered? | In-person visits offered? |
|---|---|---|---|---|
| And Still We Rise | Culturally diverse providers that offer therapy to individuals in diverse communities, including BIPoC (Black, Indigenous, people of color) and LGBTQIA+ individuals | 4 years and up | Yes | Yes |
| Aware | In-home mental health and substance use disorder treatment, including innovative home addiction treatment programs | 18 years and up | No | Yes (in-home) |
| Brightline | On-demand resources and therapy for kids and teens, including a digital platform where families can set up virtual visits and find personalized resources and guides | 3 to 17 years | Yes | No |
| Cortica | Value-based medical care, ABA therapy, counseling, and more for autistic and other neurodivergent children and their families | Birth to 21 years | Yes | Yes |
| DynamiCare | Virtual coaching and treatment of drug, alcohol, and tobacco use, offers financial rewards to encourage healthy behaviors | 13 years and up | Yes | No |
| Eleanor Health | Personalized care plans to help treat substance use disorders and other mental health conditions | 18 years and up | Yes | Yes |
| Forge | Mental health and substance use disorders for active-duty service members, veterans, first responders, and their families | 18 years and up | Yes | Yes |
| NOCD | Virtual care for obsessive compulsive disorder (OCD) through exposure and response prevention (ERP) therapy | 5 years and up | Yes | No |
| Sayftee | Family, individual, couple/relationship, and group therapy and workshops for LGBTQIA+ individuals and the people that love them | 6 years and up | Yes | Yes |
Many of our members have access to Learn to Live, a self-guided, 24/7 online support program based on Cognitive Behavioral Therapy (CBT). The program is intended to help manage social anxiety, depression, stress, anxiety, panic, insomnia, and moderate substance use. It is available in English and Spanish to members 13 and up on fully insured and self-insured accounts that offer this program.
Provider directory
Provider participation: If you need to verify if a particular provider is in our network, you can view our Find a Doctor & Estimate Costs tool.
Keep your directory information up to date: We use the information you enter in CAQH ProView to update our provider directory, so it is important to validate your information quarterly. If you do not keep your data current, or if you do not regularly review and attest to its accuracy, you could be removed from our directory. If you are a facility or group practice, we’ll reach out to you throughout the year to review and validate your information.
Providing our members with timely access to mental health care services is a top priority at Blue Cross. Our network of providers offers both in-person and virtual care options to simplify access. Learn more by clicking the links below.
Authorizations & Medical Necessity
Join today!
If you’re not already part of our expansive network of multidisciplinary mental health clinicians, consider joining today. By becoming a Blue Cross Blue Shield of Massachusetts contracted provider, you’ll be part of the solution in helping our members receive personalized and comprehensive support.
Submit a contracting application or learn how to change your status.
Telehealth
Visit our telehealth page to learn about telehealth-related payment information, covered services, how to bill, and more.Reimbursement for services is contingent upon:
- Eligibility and coverage. Always remember to verify a member’s benefits and eligibility. Accounts may incorporate riders (for example, to include or exclude out-of-network benefits) on any Blue Cross policy.
- Medical policy. Services must be considered medically necessary according to our current medical policies.
- Coding. Your coding must be consistent with our payment policies, claims review systems, and fee schedules.
For in-network providers:
- Payment is based on your fee schedule. To access your fee schedule, log in and click the Get my fee schedule link on the home page under “I need to….”
- You can collect up-front payment only for the member’s liability (copayment, deductible, or co-insurance).
- You may not balance bill the member for the difference between the allowed amount and your submitted charges.
Reminders:
- Payment is based on your fee schedule.
- You can collect up-front payment only for the member’s liability (copayment, deductible, or co-insurance).
- You may not balance bill the member for the difference between the allowed amount and your submitted charges.
Payment policies
Review our mental health related payment policies:
- Incident To Billing for Supervising Providers for Mental Health Services - Professional
- This payment policy details scenarios in which mental health providers may supervise and bill for services rendered by non-credentialed providers in their practice.
- Community Mental Health Centers
- Mental Health and Substance Use
- Telehealth (Telemedicine) - Medical Services
- Telehealth (Telemedicine) - Mental Health
To download our payment policies, log in and click Find a Payment Policy on the right side of your home page. Or, go to Office Resources>Policies & Guidelines>Payment Policies.
Review our mental health related payment policies:
Incident To Billing for Supervising Providers for Mental Health Services - Professional
- This payment policy details scenarios in which mental health providers may supervise and bill for services rendered by non-credentialed providers in their practice
Community Mental Health Centers
Telehealth (Telemedicine) - Medical Services
Telehealth (Telemedicine) - Mental Health
Psychiatric collaborative care management (CoCM)
See our detailed CoCM fact sheet to learn about this model that integrates mental health care into primary care and how to bill for it.
Billing information for children and adolescents
In accordance with the Massachusetts Division of Insurance (DOI), we cover certain mental health services to address emotional and behavioral conditions found in children and adolescents under age 19. This includes services such as In-Home Therapy (IHT) and Intensive Care Coordination (ICC).
For a comprehensive list of the treatments we cover, how to bill for them, and commonly asked questions, see our Behavioral Health for Children and Adolescents (BHCA) fact sheet.
Child psychiatry incentive program (CPIP)
If you are a child psychiatrist, you can learn about our incentive program by logging into Provider Central and going to Quality & Performance> Performance Programs>Child Psychiatry Incentive Program.
Child psychiatry incentive program (CPIP)
If you are a child psychiatrist, you can learn about this program by visiting our Child Psychiatry Incentive Program page.
Resources for mental health clinicians, primary care providers, and their patients.
Mental Health Brief
Our quarterly Mental Health Brief e-newsletter helps you stay informed about Blue Cross news that affects you. Here are the past issues:
October 2020
March 2021
July 2021
November 2021
May 2022
November 2022
March 2023
June 2023
September 2023
February 2024
Webinars
October 25, 2023: Tools and resources for mental health providers
Quick Tips
CBHC Quick Tips: for community mental health centers (CMHCs) providing emergency community behavioral health care (CBHC) services for our members
Coverage
Coverage is our health news service that reports on important health issues, including mental health stories and testimonials.
Treatment resources
See our list of Treatment Resources that span a wide range of mental health conditions, including Attention-deficit/hyperactivity disorder (ADHD), alcohol and substance abuse, depression, and post-partum depression.
Medications and substance use
- Use our medication lookup tool to see which drugs are part of our formulary.
- Visit our opioid resource center for helpful information and resources.
Resources for members
We have a dedicated mental health page on our member website, MyBlue. Share our MyBlue Mental & Behavioral Health page with your patients so they can learn about all of the resources available to them.
