Behavioral Health Care Management Program

Blue Cross and Blue Shield of New Mexico (BCBSNM) manages behavioral health services for all 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.

Blue Cross Community CentennialSM behavioral health services are managed by BCBSNM for all members who have BCBSNM Community Centennial medical benefits.

Federal Employee Program (FEP) members are managed by BCBSNM. 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 BCBSNM 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 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.

  • Blue Cross Community CentennialSM -Medicaid

    Refer to the Health Care Management section of the Blue Cross Community Centennial provider manual for information about the Medicaid behavioral health program.

    Additional information can also be found in the Behavior Health Level of Care Guidelines for Centennial Care.

  • Accreditation(s)

    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. 

  • Behavioral Health Program Components

    The BCBSNM Behavioral Health Program encompasses a portfolio of resources that help BCBSNM 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

    Blue Cross Community Centennial medical care management programs, wellness and prevention campaigns.

    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 BCBSNM. The BH Outpatient Program includes management of intensive and some routine outpatient services.

    Case Management Programs:

    • Intensive Case Management provides 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, and wellness and prevention campaigns.

  • Prior Authorization Requirements

    Members are responsible for requesting prior authorization, when prior authorization is required. 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

    Prior authorization is required for inpatient, residential treatment center (RTC) and partial hospitalization admissions that are not directly from an ER.

    Emergency hospital admissions

    • In-network unplanned or emergency hospital admissions require notification of admission to the facility. Emergency screening and stabilization services are not subject to prior authorization.
    • Out-of-network emergency screening and stabilization services are not subject to prior authorization. Out-of-network unplanned or emergency hospital admissions and post-stabilization services do not require notification. However, notification is encouraged after admission to the facility.

    Outpatient

    These outpatient services require prior authorization 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;BCBSNM would notify the provider if prior authorization is required for these testing services.

  • Prior Authorization Process

    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. BCBSNM will comply with all federal and state confidentiality regulations before releasing any information about the member.

    Inpatient and Alternative Levels of Care

    Outpatient

    For services requiring prior authorization listed in Prior Authorization Requirements

    • Use BlueApprovRSM to request prior authorization for some Behavioral Health services (visit our BlueApprovR Tools Page for instructions).
    • Members should call the behavioral health number on the back of their ID card.
    • Behavioral health providers or a members family member may request preauthorization on behalf of the member.

  • Failure to Prior Authorize

    Inpatient and Alternative Levels of Care

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

    Outpatient

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

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

  • Quality Indicators

    Behavioral Health providers have contractually agreed to offer appointments to our members according to the following appointment access standards:

    Routine: Within 10 working days

    Urgent: Within 48 hours

    Non-life threatening emergency: Within 6 hours

    Life threatening/emergency: Within 1 hour

    BCBSNM is accountable for performance on national measures such as the Health Effectiveness Data Information Sets (HEDIS). Several of these measures specify expected timeframes for appointments with a behavioral health professional.

  • Contact Information
    • Prior Authorization: Call the behavioral health number listed on the back of the member ID card
    • Submit completed BH Forms to:
      Blue Cross and Blue Shield of New Mexico BH Unit
      PO Box 660235
      Dallas, TX 75266-0235
      Fax Number: Toll-free 877-361-7659

    Note: Electronic submission of claims is strongly encouraged. Refer to Section 8 of the Provider Reference Manual for more information on filing claims electronically.  

    If you have questions, please contact:

    • Behavioral Health Member Services (for prior authorizations, benefits and eligibility): 888-898-0070 FEP members: 877-783-1385
    • Provider Service Unit (for benefits, eligibility and claims): 888-349-3706 FEP members: 800-722-3130
    • Provider Network Representatives (for application inquiries, contractual issues, provider orientation, and education): 800-567-8540
    • Contact Us

  • Additional Information

    Updates about the Behavioral Health program will be communicated in the News and Updates and Clinical Resources sections on bcbsnm.com/provider and in Blue Review.

Related Resources: