Behavioral Health Care Management Program

We provide behavioral health care coverage for many of our members. Coverage varies according to the member’s benefit plan.

Check eligibility and benefits: Use Availity® Essentials or your preferred vendor to verify membership and coverage details for every visit.

Behavioral health care management is integrated with our medical care management program. The program helps members access their behavioral health benefits and improves coordination of care between medical and behavioral health providers.

This integration helps our clinical staff identify members who could benefit from coordination between their medical and behavioral health care and may result in:

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

We may refer some members* to other programs designed to help identify and close potential gaps in care.

Starting Jan. 1, 2025, members of Blue Advantage PPOSM and Blue Preferred PPOSM individual market benefit plans purchased on or off the marketplace exchange no longer have access to out-of-state care beyond certain border counties. Members may request a waiver prior to services being approved for medical necessity. Learn more here.

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

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

  • Accreditation(s) 

    NCQA

    Our Behavioral Health Care Management Program is accredited for Health Utilization Management through the National Committee for Quality Assurance (NCQA). The accreditation is for all our health plans, covering all our members.

    About NCQA

    NCQA is a private, nonprofit organization dedicated to improving health care quality. NCQA accredits and certifies a wide range of health care organizations. It also recognizes clinicians and practices in key areas of performance.

    NCQA’s Healthcare Effectiveness Data and Information Set (HEDIS®) is the most widely used performance measurement tool in health care. NCQA’s website contains information to help consumers, employers and others make more informed health care choices.

  • Behavioral Health Care Components

    Our Behavioral Health Program provides resources that help members access benefits for behavioral health (mental health and substance abuse) conditions. The behavioral health program is part of our overall care management program.

    Behavioral Health Program components:

    Care and Utilization Management

    • Inpatient Management - Inpatient, partial hospitalization, and residential treatment center services.
    • Outpatient Management - Management of intensive services which may include services such as: Applied Behavior Analysis,  Partial Hospitalization, Intensive Outpatient Program, or Repetitive Transcranial Magnetic Stimulation. 

    Case Management Programs

    • Intensive Case Management - Intervention for members experiencing a high severity of symptoms.

    • Condition Case Management - Comprehensive coordination of care for members with chronic mental health and substance use conditions.

    • Active Specialty Management – Support for members with behavioral health needs who do not meet the criteria for intensive or condition case management.

    • Care Coordination Early InterventionSM (CCEI) – Post-discharge outreach to higher risk members who have complex psychosocial needs impacting their discharge plan.

    Specialty Programs

    • Eating Disorder Care Team – A multi-disciplinary clinical team with expertise in treating eating disorders

                    -Partners with eating disorder experts

    -Works with treatment facilities

    -Identifies members who may need care and refers to appropriate programs

    • Autism Response Team – A multi-disciplinary clinical team that provides expertise and support to families seeking autism spectrum disorder treatment. The team works with families to help them maximize their covered benefits.

    • Risk Identification and Outreach (RIO) – Our behavioral health, medical, pharmacy and clinical data technology groups work together to help members who may be at risk for substance use disorder. We use information to identify and guide members to clinically appropriate and effective care. RIO works with members who have Prime Therapeutics as their benefits manager. 

    In addition to the programs above, case managers also refer members to other medical care management programs, wellness and prevention campaigns, if appropriate.

  • Prior Authorization and Recommended Clinical Review Process

    Request prior authorization if required for a particular service. If a prior authorization is not required, submit an optional medical necessity review through our recommended clinical review process.

    Checking eligibility and benefits will determine if a prior authorization is needed. All services must be medically necessary.

    Federal Employee Program® members: The only outpatient service that requires prior authorization for FEP® members is Applied Behavior Analysis  services.

    Commercial members 
    Clinicians use the following guidelines to determine whether a requested level of care is medically necessary:

    For mental health conditions, MCG Care Guidelines. To access:

    • Log into Availity Essentials
    • Select Payer Spaces from navigation menu and choose BCBSOK
    • Select the Resources tab
    • Next, choose Resources in Filter By Category
    • Select the MCG Care Guidelines link 

    For addiction disorders, the American Society of Addiction Medicine’s The ASAM Criteria (addiction disorders), our medical policies, nationally recognized clinical practice guidelines and independent professional judgment

    Benefit availability also depends on specific provisions under the member’s benefit plan. Call the number on the member’s ID card if you have questions.  

    Government program members 
    Clinicians use the following hierarchy of clinical criteria to determine the most appropriate level of care for our members:  

    • National coverage determinations
    • Local and regional coverage determinations

     

    MCG Care Guidelines (mental health disorders). To access:

    • Log into Availity Essentials
    • Select Payer Spaces from navigation menu and choose BCBSOK
    • Select the Resources tab
    • Next, choose Resources in Filter By Category
    • Select the MCG Care Guidelines link

     

    The American Society of Addiction Medicine’s The ASAM Criteria (addiction disorders)

     

    Prior Authorization

    Prior authorization is the process of determining whether the proposed treatment or service meets the definition of “medically necessary,” as set forth in the member’s benefit plan. Prior authorization is obtained by contacting BCBSOK or the appropriate vendor for approval of services before delivering care.

    Recommended Clinical Review

    A recommended clinical review is an optional medical necessity review that is conducted before, during or after services are provided. Submitting the request prior to rendering services helps providers to identify situations in which a service may not be covered based on upon medical necessity.

    Verifying Benefits

    To determine whether prior authorization is required, always check the patient’s eligibility and benefits before providing care:

    • Submit an electronic eligibility and benefits (HIPAA 270) transaction to BCBSOK via  Availity Essentials, or through your preferred vendor portal; or
    • Call the number listed on the member's ID card.


    How to Request Prior Authorization and Recommended Clinical Review

    To request a prior authorization or recommended clinical review, use one of these methods:

    • Use the BlueApprovRSM integrated process through Availity Authorizations to request prior authorization for behavioral health services. Visit our Availity Authorizations page for information.

    -Learn more on the BlueApprovR page.

    • Availity Attachments: Recommended Clinical Review Requests – Availity Attachments tool is available for providers to upload medical documentation and submit RCR requests online. Visit the Availity Attachments: Submit Recommended Clinical Review Requests page in the Provider Tools section for more details. 
    • Phone – If you are unable to submit a request electronically, call the number on the member ID card.


    Post Service Utilization Management Review

    We may conduct a post-service utilization management review after care is rendered. We review clinical documentation to determine whether a service or drug was medically necessary and covered under the member’s benefit plan.

    During post-service reviews, we may request medical records and review claims for consistency with:

    • Medical policies
    • Provider agreement
    • Clinical payment and coding policies
    • Accuracy of payment


    Resources

    Additional information on our Behavioral Health Program is on our website. There you can view Clinical Practice Guidelines for common conditions and the medical necessity criteria.

  • Failure to Prior Authorize

    Failure to obtain Prior Authorization when it is required for Behavioral Health Services

    • If prior authorization is required but not obtained for inpatient behavioral health treatment, members may experience the same benefit reductions that apply for inpatient medical services.

    • If prior authorization is required but not obtained for outpatient behavioral health treatment, the behavioral health professional or physician will be asked to submit clinical information for a medical necessity review.

    • Medically unnecessary claims will not be reimbursed. The member may be financially responsible for services that are deemed medically unnecessary.

  • Contact Information

    Submit completed Behavioral Health Forms to
    Blue Cross and Blue Shield of Oklahoma BH Unit
    PO Box 660240
    Dallas, TX 75266-0240
    Fax Number: Toll-free 877-361-7660

    Claims submission address
    Blue Cross and Blue Shield of Oklahoma
    PO Box 655924
    Dallas, TX 75265-5924

    Federal Employee Program (FEP)
    877-906-6389

  • Additional Information

    Updates about the behavioral health program will be communicated in News and Updates, on our website and in Blue Review.

    If you have any questions, please contact your provider network representative.

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