Behavioral Health Care Management Program

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

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

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.

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, Partial Hospitalization, 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 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 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
• 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.

FEP members: The only service that requires prior authorization for FEP members is Applied Behavior Analysis 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 BCBSNM 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 BCBSNM 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 our BlueApprovR tool via Availity^® Essentials
• Availity Authorizations and Referrals - If BlueApprovR is not applicable, submit requests electronically via Availity Authorizations and Referrals
• 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.

_{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 certificate of coverage, 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 BCBSNM. BCBSNM makes no endorsement, representations or warranties regarding third party vendors and the products and services they offer.}

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.

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

Submit completed Behavioral Health Forms to
Blue Cross and Blue Shield of New Mexico BH Unit
PO Box 660240
Dallas, TX 75266-0240
Fax Number: Toll-free 877-361-7659

Claims submission address
Blue Cross and Blue Shield of New Mexico
PO Box 660058
Dallas, TX 75266-0058
Federal Employee Program (FEP^®)
Fax Number: 877-783-1385

Updates about the behavioral health program will be communicated in News and Updates, on our website and in Blue Review.

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