Behavioral Health Care Management Program
We provide behavioral health care coverage for many Blue Cross and Blue Shield of Montana 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. This 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 help close potential gaps in care.
Federal Employee Program (FEP) members are managed by BCBSMT. FEP members are not required to request prior authorization for any outpatient behavioral health services, including Partial Hospitalization Programs.
All behavioral health benefits are subject to the terms and conditions as listed in 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 provider referrals. Members must have medical care management as a part of their group health plans, in order to be referred to other medical management programs.
Accreditation
Our Behavioral Health Care Management program is accredited for Health Utilization Management through the National Committee for Quality Assurance (NCQA). The accreditation applies to all our health plans and covers 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 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, 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 abuse conditions.
- Active Specialty Management – Support for members 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
Checking eligibility and benefits will determine if a prior authorization is needed. All services must be medically necessary.
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.
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 BCBSMT or the appropriate vendor for approval of services before delivering care.
Recommended Clinical Review
A recommended clinical review is an optional review before, during or after services are provided. Its purpose is to determine medical necessity. Submitting the request prior to rendering services is optional and identifies situations in which a service may not be covered based on upon medical necessity.
Verifying Benefits
To determine whether prior authorization is required, verify eligibility and benefits before providing care:
- Submit an electronic eligibility and benefits (HIPAA 270) transaction to BCBSMT 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:
- BlueApprovRSM - If applicable, submit requests electronically using our BlueApprovR tool via Availity® Essentials
- Availity Authorizations and Referrals - If BlueApprovR is not applicable, submit requests electronically via Availity Authorizations and Referrals via Availity® Essentials
- Phone - If you are unable to submit a request electronically, call the number on the member ID card
FEP members: The only service that requires prior authorization for FEP members is Applied Behavior Analysis services.
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
If prior authorization is not obtained for 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.
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.
Quality Indicators
Access & Availability Standards
Participating providers have agreed to cooperate in monitoring accessibility of care for members, including scheduling of appointments and waiting times. Participating providers must meet the following appointment standards:
- Emergency: Services must be made available and accessible at all times (24-hour availability with qualified on-call coverage) for life threatening and non-life threatening emergencies
- Non-life-threatening emergency: Within six (6) hours or refer to ER
- Urgent: Within 24 hours
- Routine: Within 10 calendar days
Behavioral Health Appointment Access Standards
Behavioral Health providers have contractually agreed to offer appointments to our members according to the following appointment access standards:
- Initial Visit for Routine Care: Within 10 working days
- Follow-up for Routine Care: Within 30 calendar days
- Urgent: Within 48 hours
- Non-life threatening emergency: Within six (6) hours
- Life threatening/emergency: Within one (1) hour
BCBSMT is accountable for performance on national measures, like the Health Effectiveness Data Information Sets (HEDIS®). Several of these measures specify expected timeframes for appointments with a BH professional. View tips for HEDIS.)
For members discharging from an acute mental health hospital admission:
- We expect a member will have a follow-up appointment with a BH professional within seven days of a mental health inpatient discharge. If the seven-day time frame is missed, an appointment is expected within 30 days of discharge.
For members treated with Antidepressant Medication:
- Medication adherence for 12 weeks of continuous treatment (during Acute phase)
- Medication adherence for 180 days (Continuation phase)
For children (6–12 years old) who are prescribed ADHD Medication:
- One follow up visit the first 30 days after medication dispensed (Initiation phase)
- At least two (2) visits, in addition to the visit in the Initiation phase, with provider in the first 270 days after the Initiation phase ends (Continuation and Maintenance phase)
For members treated with a new diagnosis of alcohol or drug dependence (AOD):
- Treatment initiation through an inpatient admission, outpatient visit, intensive outpatient encounter, partial hospitalization program, telehealth or medication treatment within 14 days following the diagnosis (Initiation phase).
- At least 2 visits/services, in addition to the treatment initiation encounter, within 34 days of initiation visit (Engagement phase) initial diagnosis (Encounter phase)
Continuity and Coordination of Care
Continuity and coordination of care are important elements of care and as such are monitored through the BCBSMT Quality Improvement Program. Opportunities for improvement are selected across the delivery system, including settings, transitions in care, patient safety, and coordination between medical and behavioral health care.
Communication and coordination of care among all Professional Providers participating in a member’s health care are essential to facilitating quality and continuity of care. When the subscriber has signed an authorization to disclose information to a Primary Care Physician (PCP), the behavioral health provider should notify the PCP of the initiation and progress of behavioral health services.
Contact Information
Prior authorization: Call 855-313-8909 or the number listed on the member ID card.
Submit completed Behavioral Health Forms to:
Blue Cross Blue Shield of Montana
PO Box 660240
Dallas, TX 75266-0240
Fax Number: 855-649-9681
Toll-free: 855-313-8909
Paper Claims Submission Address:
Blue Cross and Blue Shield of Montana
PO Box 660255
Dallas, TX 75266-0255
Additional Information
For routine benefits, eligibility, and claim questions, call Customer Service at 800-447-7828, from 8 a.m. to 5 p.m. MT, M–F.
For new provider contracts and general provider contract questions, BCBSMT provider ID number and NPI questions, credentialing and re-credentialing status, provider roundtable meetings, and complex claims issues beyond the scope of Customer Service, Contact BCBSMT Network Management.
Related Resources:
Checking eligibility and/or benefit information, obtaining prior authorization or the fact that a recommended clinical review decision has been issued is not a guarantee of payment. Benefits will be determined once a claim is received and will be based upon, among other things, the member’s eligibility and the terms of the member’s contract including, but not limited to, exclusions and limitations applicable on the date services were rendered. Regardless of any prior authorization or recommended clinical review, the final decision regarding any treatment or service is between the patient and the health care provider.
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 BCBSMT. BCBSMT makes no endorsement, representations or warranties regarding third party vendors and the products and services they offer.
HEDIS is a registered trademark of the National Committee for Quality Assurance