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.

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 (ABA), Intensive Outpatient Program (IOP), or Repetitive Transcranial Magnetic Stimulation (rTMS). 

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 Intervention^SM (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.

• 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 First-Line Psychosocial Care for Children and Adolescents on Antipsychotics
• Use of Opioids from Multiple Providers

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® (FEP®) members: The only outpatient service that requires prior authorization for FEP members is Applied Behavior Analysis (ABA) services.

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 the secure Availity® Essentials portal, 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:

• BlueApprovR^SM – If applicable, submit requests electronically using the BlueApprovR tool via Availity Essentials. This online tool providers to submit inpatient and/or outpatient prior authorization requests for medical and surgical, specialty pharmacy drugs and behavioral health services, as well as recommended clinical review (RCR) requests for medical/surgical and specialty pharmacy drugs for many BCBSOK commercial members.

-Learn more by viewing the BlueApprovR page in the Provider Tools section.

• Availity Authorizations and Referrals – If BlueApprovR is not applicable, submit prior authorization and/or referral requests electronically via Availity’s Authorizations and Referrals tool.  Learn more by referring to the Availity Authorizations & Referral page in the Provider Tools section.
• Availity Attachments: Recommended Clinical Review (RCR) 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 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.

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

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