Behavioral Health Outpatient Management Program

The BCBSNM Behavioral Health (BH) Outpatient Management Program includes the management of intensive and some routine outpatient services.

The benefit of the full Program – inpatient and outpatient management - is that it allows the BH team to assist members throughout the entire continuum of their BH care and treatment. This structure allows the BH team to follow/monitor members as they step down from intensive levels of care (inpatient, residential, partial hospitalization) to less intensive levels (intensive outpatient, routine outpatient), ensuring that they have access to the most appropriate and effective treatment.

The Program also allows the BH team to “touch” every member who utilizes BH services via our state-of-the-art analytics to identify those who could potentially benefit from our array of programs and services. Our experience has been that members who have consistent support throughout all levels of BH treatment are more likely to experience fewer readmissions and a more positive treatment outcome.

The Program is designed to reduce the administrative burden and improve collaboration and satisfaction with our providers yet ensure members maximize the benefits available to them and avoid claims costs for medically unnecessary care.

Components of Outpatient Management include:

Management of intensive outpatient services by preauthorization and concurrent reviews. The pre-authorization allows the opportunity to ensure these intensive services are medically necessary, clinically appropriate and are likely to contribute to a successful treatment outcome. These intensive services are:

  • „Intensive Outpatient Programs (IOPs)
  • „Outpatient Electroconvulsive Therapy (ECT)
  • „Repetitive Transcranial Magnetic Stimulation (rTMS)
  • „Psychological and Neuropsychological Testing in some cases (BCBSNM will notify the provider if preauthorization is required for these testing services).

Management of routine outpatient services via our Focused Outpatient Management Program. This program is a claims-based approach to behavioral health care management that uses data-driven analysis (medical, behavioral health and pharmacy data) and clinical intelligence rules to identify members whose care and treatment may benefit from further review and collaboration.

How does the Focused Outpatient Management Program work?

The cornerstone of this model is outreach and engagement from BCBSNM BH clinicians to the identified providers and members to discuss treatment plans and benefit options. The goal is to collaborate with providers and members to maximize the benefits available to the member under his or her benefit plan.

When a member is identified through the program as potentially benefiting from further review and collaboration, BCBSNM will contact the member’s provider by letter and request additional clinical information about the member’s care and treatment. The provider will be asked to complete an enclosed Clinical Update Request Form and return it to BCBSNM within 30 days of the date of the letter. Clinical information provided will be reviewed by Behavioral Health clinical staff for further recommendations and determination of coverage based on member benefit plans.

The purpose of the clinical review is to discuss the current treatment plan and to identify and address the appropriate level, intensity and duration of the outpatient treatment needed. The review also provides the opportunity to discuss the availability of additional benefits, the potential need for more intensive treatment or community-based resources, and the benefit of integrated care and/or condition management programs where appropriate.

In addition to the provider outreach and collaboration described above, BCBSNM will also send a letter to the member to inform him or her that their provider has been asked to provide clinical information to BCBSNM to ensure the member is getting medically necessary and appropriate quality care and treatment. The letter will explain that the member’s current treatment is approved during this 30-day period. If the provider does not submit the requested information within the 30-day timeframe, BCBSNM may not be able to determine if the care and treatment provided is medically necessary or appropriate. As a result, authorization for continued services may be discontinued and the member may be financially responsible.

What should I do if I am contacted about behavioral health services?

Providers will be notified by letter that the member’s routine care and treatment may benefit from further review and collaboration through the Behavioral Health Focused Outpatient Management Program. To assist in this effort, you will be asked to complete a Clinical Update Request Form which will be included in the initial notification. BCBSNM will review the information provided for further recommendations and make a determination of coverage based on member benefit plans. If BCBSNM does not receive this important clinical information within 30 days from the date of the letter, claim reimbursement for applicable services may be denied. If BCBSNM is unable to determine that these services meet the criteria for medical necessity as outlined in the member’s benefit plan, the member may be financially responsible for those services.

Related Resources:

The Behavioral Health program is available only to members enrolled in a BCBSNM health plan that includes behavioral health benefits through BCBSNM.