Collaborating with you across the mental health continuum of care
June 2, 2025
This article is for hospitals, residential treatment facilities, clinics, and community mental health centers (CMHCs) that provide mental health and/or substance use disorder services, partial hospitalization programs (PHPs), and intensive outpatient programs (IOPs).
We are focused on making high-quality, cost-effective care available to our members. To that end, we are updating our utilization management process to provide more support for members receiving mental health services. Our goal is to better support our members with intensive treatment needs, including those transitioning from hospitals or subacute settings.
What we’re doing
- Improving care planning by contacting you sooner during the clinical review process. We are updating our utilization review process to better support members* with complex conditions and expected longer treatment episodes. You can expect more outreach from our care managers for assistance with discharge planning and aftercare referrals.
- Creating a medical policy to help you better understand our coverage. We have created a new medical policy for partial hospitalization and intensive outpatient programs. It includes information on authorization requirements, program licensure and accreditation, and clinical service components for each level of care. Our Behavioral Health Continuum of Care medical policy 194 takes effect July 1, 2025. You can email ebr@bcbsma.com to request a copy of the medical policy.
What this means for you
- Increased support from us to help with transition planning. Our goal is to help members avoid readmissions and ensure aftercare is well matched to their needs. You will have more frequent contact with our reviewers and care managers for members with complex needs.
- Help
from our Mental Health Advocates to assist in the transitions of care needed. We have added a number of new innovative outpatient provider network options that our advocates can help refer your patients to, in addition to our traditional network of more than 21,000 quality mental health clinicians.
- Guidance on coverage. Our new medical policy provides clarification on service requirements; see link above for details.
- No change to the medical necessity criteria we use. We continue to use InterQual® criteria to determine medical necessity for services.
*Commercial and Medicare Advantage members. Please remember that for HMO members, PHP and IOP services must be delivered in-network. Any out-of-network exceptions require prior authorization.
Questions?
For questions about:
- Program requirements or authorization processes for mental health services, please contact Network Management and Credentialing Services at 1-800-316-BLUE (2583).
- For member-specific clinical authorization questions, please contact our Health Management team at 1-800-524-4010.
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