1. health and fitness

BEHAVIORAL HEALTH
SERVICES
TABLE OF CONTENTS
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 461
OVERVIEW
......
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .461
Exceptions
........
. . . . . . . . . . .Patients
Referring
. . . . . . . . .for
. . . Behavioral
. . . . . . . . . . . .Health
. . . . . . . Services
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .461
........
. . . . . . . . . . . . . with
Contracting
. . . . . .ValueOptions
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .462
........
. . . . . . . . . . .BEHAVIORAL
EMBLEM
. . . . . . . . . . . . . . .HEALTH
. . . . . . . . . SERVICES
. . . . . . . . . . . PROGRAM
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 462
......
. . . . . . . . . . . . of
Continuity
. . .Care
. . . . . During
. . . . . . . . Program
. . . . . . . . . .Implementation
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .463
........
. . . . . . . . . . . . . . . .MANAGEMENT
BEHAVIORAL
. . . . . . . . . . . . . . . . . PROGRAM
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 464
......
. . . . . . . .APPROVAL
PRIOR
. . . . . . . . . . . . REQUIREMENTS
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 464
......
. . . . . . . . . Outpatient
Routine
. . . . . . . . . . . . Services
. . . . . . . . . -. .No
. . . Prior
. . . . . . Approval
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .464
........
. . . . . . . . . .Requiring
Services
. . . . . . . . . . .Prior
. . . . . Approval
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .464
........
. . . . . . . . . . . .Prior
Obtaining
. . . . . Approval
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .465
........
. . . . . . .MANAGEMENT
CASE
. . . . . . . . . . . . . . . . . PROGRAM
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 465
......
. . . . . . . . . . . . . . . CARE
DEPRESSION
. . . . . . .PATH
. . . . . . DISEASE
. . . . . . . . . . MANAGEMENT
. . . . . . . . . . . . . . . . . .PROGRAM
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 465
......
. . . . . . . . . . . . . . . .PRIMARY
TEENSCREEN
. . . . . . . . . . .CARE:
. . . . . . .MENTAL
. . . . . . . . . .HEALTH
. . . . . . . . . CHECKUPS
. . . . . . . . . . . . . FOR
. . . . . TEENS
. . . . . . . . . . . . . . . . . . . . . . . 466
......
. . . . .Mental
The
. . . . . . . .Health
. . . . . . . Checkup
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .466
........
. . . . . .Primary
Why
. . . . . . . . .Care
. . . . . Practitioners
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .466
........
. . . . . .to
How
. . Get
. . . . .Started
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .466
........
. . . . . . . . . . HEALTH
MENTAL
. . . . . . . . . .PARITY
. . . . . . . . AND
. . . . . .ADDICTION
. . . . . . . . . . . . . .EQUITY
. . . . . . . . .ACT
. . . . .OF
. . . .2008
. . . . . .(MHPAEA)
. . . . . . . . . . . . . . . . . . . . . . 468
......
Back to Table of Contents
EmblemHealth Provider Manual
Last Updated: 09/03/2014
460
BEHAVIORAL HEALTH SERVICES
In this chapter, you'll find our policies and procedures for mental health and substance abuse
services, including:
Prior approval procedures
Post-discharge protocols
Mental Health Parity Law
OVERVIEW
EmblemHealth has engaged ValueOptions® to administer behavioral health services for most
of its members under two programs. Members of plans underwritten by GHI HMO, HIP and
HIPIC, and administered by VHMS have their behavioral health services administered by
ValueOptions under the Emblem Behavioral Health Services Program (EBHSP). Members of
EPO/PPO plans underwritten by GHI have their behavioral health services administered by
ValueOptions under the EmblemHealth Behavioral Management Program (BMP).
Under EBHSP, ValueOptions administers all covered inpatient, outpatient and ambulatory
behavioral health services and is responsible for provider network and care management
services such as credentialing, claims processing, claims payment, utilization management, case
management, grievances and appeals (except for Medicare plans), and all other provider service
issues related to behavioral health.
Under BMP, ValueOptions manages all covered inpatient, outpatient and ambulatory
behavioral health services, including provider network and care management services such as
utilization management and case management. All provider claims should be submitted to
EmblemHealth, except those for Medicare members; these claims should be submitted to
ValueOptions. All appeals and grievances should be submitted to ValueOptions, except for
those of Medicare members; these appeals and grievances should be submitted to
EmblemHealth.
Exceptions
Members who have the Montefiore logo in the lower left corner of their ID card
These members access behavioral health providers in the Montefiore network. They also may
use the ValueOptions network if they choose. For providers who are not Montefiore network
participants, claims for members who have the Montefiore logo on their ID card must be
submitted to ValueOptions. Utilization management functions for behavioral health services
for these members, including prior approvals, are performed by Montefiore.
(Please refer to the Your Plan Members chapter for examples of ID cards with the Montefiore
logo.)
EmblemHealth administers disease management, including the Depression Disease
Management program, for all members.
Referring Patients for Behavioral Health Services
Providers must be contracted in the ValueOptions network(s) to provide covered behavioral
health care to members served by BMP and EBHSP.
Back to Table of Contents
EmblemHealth Provider Manual
Last Updated: 09/03/2014
461
BEHAVIORAL HEALTH SERVICES
You and your patients are able to find EBHSP and BMP practitioners and facilities by going to
the Find a Doctor tool of www.emblemhealth.com and entering the patient's ID number at the
beginning of the search. Since some of our benefit plans use different networks, entering the
patient's ID number will ensure that the search locates a provider that participates in the
patient's benefit plan.
Contracting with ValueOptions
EBHSP
To care for all members served by the EBHSP, providers are required to participate in both of
the ValueOptions practitioner networks and must have both a ValueOptions practitioner
agreement and a CHCS IPA agreement (collectively referred to as "ValueOptions Agreements").
Providers who only have a CHCS IPA agreement will only be permitted to provide in-network
care to members of HIP HMO (including commercial, HIP Medicaid, HIP Family Health Plus,
HIP Child Health Plus, and EmblemHealth Medicare HMO) and GHI HMO lines of business.
Providers who only have a ValueOptions practitioner agreement will only be permitted to
provide in-network care to members of HIPIC's EPO and PPO plans and VHMS ASO
accounts.
BMP
To care for members served by the BMP, providers are only required to have a ValueOptions
practitioner agreement.
For more information about contracting with ValueOptions, please call their Provider Line at
1-800-397-1630 and ask to speak with the Credentialing department.
EMBLEM BEHAVIORAL HEALTH SERVICES PROGRAM
As of January 1, 2012, behavioral health services for members in plans underwritten by GHI
HMO and HIP or in ASO plans administered by VHMS (as previously described in the
"Overview") are administered by ValueOptions under the Emblem Behavioral Health Services
Program.
Benefit plans served by EBHSP include:
EmblemHealth:
EmblemHealth CompreHealth EPO
EmblemHealth Medicare HMO plans (which includes Dual Eligible Group HMO SNP, Dual
Eligible HMO SNP, VIP Essential HMO, VIP High Option HMO, VIP HMO, VIP Premier
Group HMO and VIP Rx Carveout HMO)
GHI HMO:
GHI HMO
GHI HMO Direct Access HMO
GHI HMO Value Plan
HIP:
Direct Pay HMO/POS
HIPaccess® I
Back to Table of Contents
EmblemHealth Provider Manual
Last Updated: 09/03/2014
462
BEHAVIORAL HEALTH SERVICES
HIPaccess® II
HIP Prime® EPO/HMO/POS/PPO
HIP Select® EPO/PPO
Medicaid Managed Care
Family Health Plus
Child Health Plus
FEHB
Vytra HMO
VHMS: ASO accounts
Continuity of Care During Program Implementation
For Patients in an Active Course of Treatment Prior to January 1, 2012
For dates of service prior to January 1, 2012, EmblemHealth was responsible for behavioral
health services provided to HIP and VHMS members and Magellan Health Services was
responsible for behavioral health services provided to GHI HMO members.
Patients who are in an active course of treatment with a provider who has declined network
participation in the EBHSP or has not completed the necessary application, credentialing and
contracting processes with ValueOptions as of January 1, 2012 may elect to continue
treatment with the provider for a period up to 90 days, so long as the provider accepts the
applicable current fee schedule and follows the existing policies and procedures.
This will support continuity of care until the member can find a new provider who can meet
their needs.
Routine Outpatient Care
Providers who do not participate in the ValueOptions network(s) delivering routine outpatient
behavioral health treatment do not need to obtain approval to provide routine outpatient care
during the 90 day transition period.
Non-routine Outpatient Care
Providers must contact ValueOptions to obtain prior approval to deliver continuing
non-routine outpatient care for dates of service beginning January 1, 2012.
Alternative Level of Care (Partial hospitalization, Intensive Outpatient)
If the patient is in an alternative level of care initiated or authorized by EmblemHealth or
Magellan Health Services (as applicable) prior to the transition date and needs to continue that
level of care after the transition date, the provider should contact EmblemHealth or Magellan
Health Services (as applicable) for concurrent approval.
Intensive outpatient behavioral health services will require a prior approval from ValueOptions
for dates of service beginning January 1, 2012.
Inpatient Care
EmblemHealth and Magellan Health Services (as applicable) are responsible for medical
management and for adjudicating claims for inpatient care initiated prior to the
commencement of the EBHSP until the patient is discharged and/or moved to an alternate level
Back to Table of Contents
EmblemHealth Provider Manual
Last Updated: 09/03/2014
463
BEHAVIORAL HEALTH SERVICES
of care. At that point, responsibility for utilization and claims management will transition to
ValueOptions.
BEHAVIORAL MANAGEMENT PROGRAM
Members of EPO and PPO plans underwritten by GHI have their behavioral health services (as
previously described in the "Overview") administered by ValueOptions under the Behavioral
Management Program (BMP).
Benefit plans served by BMP include:
EmblemHealth:
EmblemHealth ConsumerDirect EPO/PPO
EmblemHealth EPO/PPO
EmblemHealth InBalance EPO/PPO
EmblemHealth Medicare PPO plans (which includes Dual Eligible PPO, SNP, Group Access
PPO, Group Access RX PPO, Medicare ASO accounts [GuildNet Gold and ArchCare],
Medicare PPO I, Medicare PPO II, Medicare PPO III and PPO High Option)
GHI:
DC37 Med Team Program
EPO/PPO Share
Federal Employees Health Benefits Program (FEHB)
GHI/CUNY Student Health Insurance Program
H.E.R.E.I.U.
Network Access
NYCTA TWU
PRIOR APPROVAL REQUIREMENTS
In some cases, coverage of behavioral health services to a member served by EBHSP or BMP
requires a prior approval before the service can be rendered. Members may be subject to a
copay and/or deductible depending on their benefit plan.
Routine Outpatient Services - No Prior Approval
Prior approval is not required for routine outpatient services. These services include initial
consultation and individual, group, family, couple and collateral treatment. ValueOptions will,
however, reach out to practitioners when there are questions regarding the member's clinical
treatment.
Services Requiring Prior Approval
Prior approval is always required for the following services:
Inpatient behavioral health treatment
Ambulatory detoxification treatment
Outpatient ECT (electro-convulsive treatment)
Partial hospitalization
Back to Table of Contents
EmblemHealth Provider Manual
Last Updated: 09/03/2014
464
BEHAVIORAL HEALTH SERVICES
Intensive outpatient treatment
Neuropsychological testing
Psychological testing
Obtaining Prior Approval
If you are a behavioral health provider and your patient is served by EBHSP or the BMP you
must contact ValueOptions directly to obtain prior approval when necessary. Once
ValueOptions approves the service, you must notify your patient of the approval. You must
notify ValueOptions if you are unable to reach your patient (or his or her designee).
The telephone numbers to contact for prior approval are:
EBHSP: 1-888-447-2526
BMP: 1-800-692-2489
CASE MANAGEMENT PROGRAM
The Case Management Program is administered by ValueOptions for all members (except for
those with the Montefiore logo on their ID card).
Patients who have the greatest risk of needing intensive behavioral health services including
inpatient care are eligible for case management services. Patients are identified through
multiple sources including provider referrals.
An enrolled patient is assigned a case manager who will contact them, devise a treatment care
plan and will work with their treatment provider(s) to assist with medication adherence and
treatment plan compliance. The Case Management Program involves frequent telephonic
counseling sessions between the case manager and patient to aid the patient in staying out of
the hospital.
To refer a patient to the Case Management Program, please call the Mental Health number on
the back of the member's ID card.
DEPRESSION CARE PATH DISEASE MANAGEMENT
PROGRAM
Any plan member who is receiving antidepressant medication and/or has a major depression
diagnosis is eligible to participate in the Depression Care PATH (Positive Actions Toward
Health) program, which is administered by EmblemHealth.
The Depression Care PATH program provides educational resources and phone outreach to
help your patient self-manage depression. Health coaches, who are licensed social workers,
provide members with:
Access to educational materials about depression
Answers to frequently asked questions and concerns about depression
Back to Table of Contents
EmblemHealth Provider Manual
Last Updated: 09/03/2014
465
BEHAVIORAL HEALTH SERVICES
Assistance making appointments with mental health professionals
Assistance coordinating care
Coaching calls, including the importance of medication adherence
Assessment of depression severity
To refer a patient to the Depression Care PATH Program, call 1-800-447-0769.
TEENSCREEN PRIMARY CARE: MENTAL HEALTH
CHECKUPS FOR TEENS
EmblemHealth participates in TeenScreen® Primary Care, an initiative that offers annual
standard mental health checkups to adolescent patients through their primary care
practitioners. Patients 11 to 18 years of age with GHI, GHI HMO, HIP or EmblemHealth
coverage are eligible to participate in the program.
TeenScreen Primary Care in an initiative of the National Center for Mental Health Checkups at
Columbia University.
The Mental Health Checkup
The mental health checkup includes a brief questionnaire that patients complete in the waiting
or exam room. The questionnaire can help evaluate if a teen is suffering from depression,
anxiety or other condition. When the mental illness is identified early, teens have the best
chance to lead healthy lives and reach their full potential.
Why Primary Care Practitioners
Primary care practitioners are in a unique position to help detect mental health conditions.
According to the US Surgeon General, 21 percent of our nation's youth suffers from a
diagnosable mental disorder that causes impairment, but 80 percent are not identified and do
not receive help. Further, about two million teenagers are affected by depression; however,
most of these teens go undiagnosed and untreated.
Mental health screening is an effective way to identify at-risk teens and is recommended by the
US Preventive Services Task Force the Institute of Medicine, the American Academy of
Pediatrics, the American Academy of Family Physicians and the National Association of
pediatric Nurse Practitioners.
How to Get Started
Primary care practitioners who are interested in providing mental health checkups to their
teen patients will receive the Pocket Guide for mental health checkups. The guide provides all
the information you and your staff needs to participate in the program, including:
Evidence-based screening questionnaires and other resource materials
Information on obtaining reimbursement for screening
Information on accessing immediate referrals from network resources through our mental
health partners
Ongoing support and technical assistance
Back to Table of Contents
EmblemHealth Provider Manual
Last Updated: 09/03/2014
466
BEHAVIORAL HEALTH SERVICES
To request these materials, please e-mail MentalHealthCheckups@childpsych.columbia.edu or
call 1-212-265-4426.
Snapshots of the Pocket Guide & Screening Questionnaire
Reimbursement Codes for a Mental Health Checkup during a Well-child Exam
Back to Table of Contents
EmblemHealth Provider Manual
Last Updated: 09/03/2014
467
BEHAVIORAL HEALTH SERVICES
MENTAL HEALTH PARITY AND ADDICTION EQUITY ACT
OF 2008 (MHPAEA)
On October 3, 2008 Congress enacted the MHPAEA. The MHPAEA applies to large group,
CHIPS and Medicare members whose group enrolled in the plan on or after October 3, 2009.
Under the MHPAEA, the expanded coverage for behavioral health services enacted by the New
York State legislature under Timothy's Law was further enhanced to include substance abuse
treatment and non-biologically based mental health treatment.
As a result of the MHPAEA, there is no day or visit limitation for members covered by the act
who have a behavioral health benefit and meet medical necessity criteria. Prior approval
requirements continue to apply to these services.
As of November 1, 2009 there are no limits to behavioral health services for Child Health Plus
members.
Back to Table of Contents
EmblemHealth Provider Manual
Last Updated: 09/03/2014
468