Behavioral Health Care Management Program

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.

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 Intervention^SM (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 medical care management programs, wellness and prevention campaigns.

• Antidepressant Medication Management 
• Diabetes Screening for People with Schizophrenia, Schizoaffective Disorder or Bipolar Disorder Who Are Using Antipsychotic Medications 
• Follow-Up After Emergency Department Visit for Substance Use
• Follow-Up After Emergency Department Visit for Mental Illness 
• Follow-Up After High-Intensity Care for Substance Use Disorder (FUI)
• Follow-Up after Hospitalization for Mental Illness 
• Follow-Up Care for Children Prescribed ADHD Medication 
• Initiation and Engagement of Substance Use Disorder Treatment 
• Medication Assisted Treatment provider criteria 
• Metabolic Monitoring for Children and Adolescents on Antipsychotics
• Pharmacotherapy for Opioid Use Disorder (POD)
• Prenatal and Postpartum Depression Screening and Follow-Up
• Use of Opioids from Multiple Providers

Members are responsible for requesting prior authorization before treatment, when prior authorization is required. Behavioral health providers or a member's family member may request prior authorization on behalf of the member. BCBSOK will comply with all federal and state confidentiality regulations before releasing any information about the member. All services must be medically necessary.

Inpatient and Alternative Levels of Care

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

• Elective or non-emergency hospital admissions must be authorized 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 intensive outpatient services require authorization prior to initiation of service to determine that the services are medically necessary, clinically appropriate and contribute to the successful outcome of treatment.

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

This requirement applies only for members who have BH Outpatient Management as part of their BH benefit plan through BCBSOK.

Additionally, FEP members must request prior authorization for Applied Behavior Analysis (ABA) services but are not required to request prior authorization for any other outpatient behavioral health services including Partial Hospitalization Programs.

Members are responsible for requesting prior authorization when prior authorization is required, although behavioral health providers or a member's family member may request prior authorization 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.
• Or if instructed by Availity® Essentials use BlueApprovR^SM to request prior authorization for some services (visit our BlueApprovR Provider Tools Page for instructions)

Outpatient

• Members should call the behavioral health number on the back of their ID card.
• Or if instructed by Availity® Essentials use BlueApprovR^SM to request prior authorization for some services (visit our BlueApprovR Provider Tools Page for instructions)
• Behavioral health providers or a member’s family member may request prior authorization on behalf of the member. BCBSOK will comply with all federal and state confidentiality regulations before releasing any information about the member.
• Prior authorization for these services requires completion of a form(s) located at bcbsok.com/provider under the Education and Reference Center tab - Forms.
• Prior authorization requirements for ABA services are outlined in the Behavioral Health Outpatient Management Program located in the Related Resources section of this website.

You may still request prior authorization by phone for services through BCBSOK

• Or call the phone number listed on the member’s ID card.

Availity is a trademark of Availity, LLC, a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to BCBSOK. BCBSOK makes no endorsement, representations or warranties regarding third party vendors and the products and services they offer.

Inpatient and Alternative Levels of Care

Members who do not request prior authorization for inpatient and alternative levels of care behavioral health treatment may experience the same benefit reductions that apply to medical services. Medically unnecessary claims will not be reimbursed.

Outpatient

If a member receives any of the behavioral health services listed below without prior authorization, BCBSOK will request clinical information from the provider for a medical necessity review. The member will also receive notification.

• Intensive Outpatient Programs (IOP)
• Applied Behavior Analysis (ABA)
• Outpatient Electroconvulsive therapy (ECT)
• Repetitive Transcranial Magnetic Stimulation (rTMS)
• Psychological and Neuropsychological testing in some cases; BCBSOK would notify the provider if prior authorization 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 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

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

Related Resources

• 2020 Behavioral Health Program Change FAQs 
• Behavioral Health Outpatient Management Program  
• Behavioral Health Quality Improvement Program
• Behavioral Health Unit Contact Information
• Clinical Practice Guidelines
• Forms
• Medical Necessity Criteria