Behavioral Health Care Management Program

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

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 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 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 BCC medical care management programs, and wellness and prevention campaigns.

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.

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

• Use BlueApprovR^SM to request prior authorization for some Behavioral Health services (visit our BlueApprovR Tools Page for instructions).
• Call the appropriate number on the back of the member's ID card.

Outpatient

For services requiring prior authorization listed in Prior Authorization Requirements

• Use BlueApprovR^SM 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.

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.

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.

• Expectation that a member has a follow up appointment with a BH professional following a mental health inpatient admission within 7 and 30 days
  • Follow-Up Care for Children Prescribed ADHD Medication (ADD) Tip Sheet
    • Children ages 6 to 12
    • Newly filled attention-deficit hyperactivity disorder (ADHD) medication
    • Prescribed in the ambulatory setting
    • Follow-up visits in two phases
  • Antidepressant Medication Management (AMM) Tip Sheet
    • Members ages 18 and older
    • Diagnosed with major depression
    • Newly filled antidepressant medication
    • Continuation of medication in two phases
  • Diabetes Screening for Members Taking Antipsychotics (SSD) Tip Sheet
    • Members ages 18 to 64
    • Diagnosed with schizophrenia, schizoaffective disorder or bipolar disorder
    • Received an antipsychotic medication at any time during the year
  • Initiation and Engagement of Substance Use Disorder Treatment
    • Other Drug Abuse or Dependence Treatment (IET) Members 13 years and older
    • New diagnosis of Alcohol or Other Drug Dependence
    • Follow-up visits in two phases
      • At least one visit in 14 days
      • At least two more in 34 days

• 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

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.