Behavioral Health Care Management Program



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Blue Cross and Blue Shield of Oklahoma (BCBSOK) manages behavioral health services for all non-HMO members who have behavioral health benefits through a variety of group, government and retail products. Similar behavioral health programs are implemented across product lines but may be modified or enhanced dependent upon the product.


For HMO members, behavioral health and substance abuse services are delivered by Magellan Health Services' provider network.


Federal Employees Program (FEP) members are managed by BCBSOK. FEP members are not required to request preauthorization for any outpatient behavioral health services including Partial Hospitalization Programs.


Behavioral health care management is integrated with our medical care management program, as part of Blue Care Connection® (BCC), to help members access their behavioral health benefits and to improve coordination of care between medical and behavioral health providers.


This program will help BCBSOK clinical staff identify members who could benefit from co-management earlier, and may result in:

  • Improved outcomes
  • Enhanced continuity of care
  • Greater clinical efficiencies
  • Reduced costs over time


Some members* may be referred to other BCC medical care management programs that are designed to help identify and help close potential gaps in care through evidence-based and member-focused approaches to health care and benefit decisions.


All behavioral health benefits are subject to the terms and conditions as listed in the member's benefit plan.


* Members experiencing inpatient hospitalization, complex or special health care needs or who are at risk for medical complications may be referred to BCC programs through a variety of mechanisms such as predictive modeling, claim utilization, inbound calls, self-referrals, and physician referrals. If members do not have BCC as part of their group health plans, they will not be referred to other BCC programs.





Health Care Service Corporation, Inc. (operating through its five divisions: BCBS of Illinois, BCBS of Montana, BCBS of New Mexico, BCBS of Oklahoma, and BCBS of Texas) Behavioral Health Care Management program has been accredited for Health Utilization Management since October of 2012. This accreditation covers the Behavioral Health Utilization Management program for Commercial/Group, FEP and Retail Exchange Affected Markets lines of business for all five plan states.


URAC, an independent, nonprofit organization, is well-known as a leader in promoting health care quality through its accreditation and certification programs. URAC offers a wide range of quality benchmarking programs and services that keep pace with the rapid changes in the health care system, and provide a symbol of excellence for organizations to validate their commitment to quality and accountability. Through its broad-based governance structure and an inclusive standards development process, URAC strives to ensure that all stakeholders are represented in establishing meaningful quality measures for the entire health care industry. For more information, visit www.urac.org.



The BCBSOK Behavioral Health Program encompasses a portfolio of resources that help BCBSOK members access benefits for behavioral health (mental health and substance abuse) conditions as part of an overall care management program. It also allows our clinical staff to assist in the early identification of members who could benefit from co-management of behavioral health and medical conditions.


Behavioral Health Program components:

  • Care/Utilization Management:
    • Inpatient Management for inpatient, partial hospitalization, residential treatment center services, and some outpatient behavioral health care services
    • Outpatient Management for members who have outpatient management as part of their behavioral health benefit plan through BCBSOK. The BH Outpatient Program includes management of intensive and some routine outpatient services.
  • Case Management Programs:
    • Intensive Case Management provides more intensive levels of intervention for members experiencing a high severity of symptoms.
    • Condition Case Management provides a comprehensive, integrated approach to the coordination of care for members with the following chronic mental health and substance abuse conditions:
      • Depression
      • Alcohol and Substance Abuse Disorders
      • Anxiety and Panic Disorders
      • Bipolar Disorders
      • Eating Disorders
      • Schizophrenia and other Psychotic Disorders
      • Attention Deficit and Hyperactivity Disorder (ADD/ADHD)
    • Active Specialty Management program for members who do not meet the criteria for Intensive or Condition Case Management but who have behavioral health needs and could benefit from extra support or services.
    • Care Coordination Early InterventionSM (CCEI) Program provides outreach to higher risk members who often have complex psychosocial needs impacting their discharge plan.
    • Patient Safety Program provides outreach calls to members that may have the potential of becoming higher risk for readmission(s) and/or frequent Emergency Room visits. The goal of the outreach is to provide resources and/or to ensure they have access to the treatment they need.
  • Specialty Programs:
    • Eating Disorder Care Team is a dedicated clinical team with expertise in the treatment of eating disorders. The team includes partnerships with eating disorder experts and treatment facilities as well as internal algorithms to identify and refer members to appropriate programs.
    • Autism Response Team whose focus is to provide expertise and support to families in planning the best course of Autism Spectrum Disorder (ASD) treatment for their family, including how to maximize their covered benefits.
  • Referrals to other BCC medical care management programs, wellness and prevention campaigns.


Members are responsible for requesting preauthorization before treatment, when preauthorization is required. Behavioral health providers or a member's family member may request preauthorization on behalf of the member. All services must be medically necessary.


Inpatient and Alternative Levels of Care


Preauthorization is required for all inpatient, residential treatment center (RTC) and partial hospitalization admissions.

  • Elective or non-emergency hospital admissions must be preauthorized prior to admission or within two business days of an emergency admission.
  • To determine eligibility and benefit coverage prior to service and to determine if RTC services are covered by a specific employer group, members or behavioral health professionals and physicians may call the Behavioral Health number that is listed on the back of the member's ID card


Outpatient


These outpatient services require preauthorization prior to initiation of service:

  • Intensive Outpatient Program (IOP)
  • Outpatient Electroconvulsive therapy (ECT)
  • Repetitive Transcranial Magnetic Stimulation (rTMS)
  • Psychological and Neuropsychological testing in some cases; BCBSOK would notify the provider if preauthorization is required for these testing services.


Members are responsible for requesting preauthorization when preauthorization is required, although behavioral health providers or a member's family member may request preauthorization on behalf of the member. All services must be medically necessary.


Inpatient and Alternative Levels of Care

  • Call the appropriate number on the back of the member's ID card.


Outpatient

  • Members should call the behavioral health number on the back of their ID card.
  • Behavioral health providers or a member’s family member may request preauthorization on behalf of the member. BCBSOK will comply with all federal and state confidentiality regulations before releasing any information about the member.

  • Intensive Outpatient Program (IOP)
  • Outpatient Electroconvulsive therapy (ECT)
    • Repetitive Transcranial Magnetic Stimulation (rTMS)
    • Psychological and Neuropsychological testing in some cases; BCBSOK would notify the provider if preauthorization is required for these testing services.

  • Preauthorization:
    Call 800-672-2378 or the preauthorization number listed on the back of the member ID card

  • Submit completed Behavioral Health Forms to:
    Blue Cross and Blue Shield of Oklahoma BH Unit
    PO Box 660239
    Dallas, TX 75266-0239
    Fax Number: Toll-free 877-361-7660

  • Claims submission address:
    Blue Cross and Blue Shield of Oklahoma
    PO Box 3283
    Tulsa, OK 74102-3283

  • Federal Employee Program (FEP):
    877-906-6389


  • Updates about the Behavioral Health program will be communicated in the News and Updates and Clinical Resources sections on bcbsok.com/provider and in Blue Review.
  • If you have any questions, please contact your provider network representative.