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Blue Cross and Blue Shield of Illinois (BCBSIL) manages behavioral health services for all non-HMO 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.

For HMO members, all behavioral health services (mental health and substance use disorders) are managed by the member's MG/IPA. Download wolf 3d browser game backuptype.

Federal Employees Program (FEP) members are managed by BCBSIL. FEP members must request preauthorization for Applied Behavior Analysis (ABA) services but are not required to request preauthorization for any other 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 BCBSIL 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 help 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.

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 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.

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

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

Case Management Programs

• Intensive Case Management provides more intensive levels of intervention for members experiencing a high severity of symptoms.
• Condition Case Management for chronic BH conditions such as:
  • 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 (CCEI)^® Program provides outreach to higher risk members who often have complex psychosocial needs impacting their discharge plan.

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, wellness and prevention campaigns

Members are responsible for requesting preauthorization when preauthorization is required. Behavioral health providers or a member’s family member may request preauthorization on behalf of the member. BCBSIL will comply with all federal and state confidentiality regulations before releasing any information about the member. All services must be medically necessary.

Inpatient and Alternative Levels of Care

Preauthorization is required for all inpatient, residential treatment center (RTC) and partial hospitalization admissions. Acl software tool.

• Elective or non-emergency hospital admissions must be preauthorized prior to admission or within two business days of an emergency admission.
• To determine eligibility and benefit coverage prior to service and to determine if RTC services are covered by a specific employer group, members or behavioral health professionals and physicians may call the Behavioral Health number that is listed on the back of the member’s ID card
• Partial Hospital Program (PHP)

Outpatient

These intensive outpatient services require preauthorization to determine that the services are medically necessary, clinically appropriate and contribute to the successful outcome of treatment.

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

This requirement applies only for members who have outpatient management as part of their behavioral health benefit plan through BCBSIL.

Additionally, FEP members must request preauthorization for Applied Behavior Analysis (ABA) services but are not required to request preauthorization for any other outpatient behavioral health services including Partial Hospitalization Programs.

Information on prior authorization requirements for BCBSIL Government Programs is available at http://www.bcbsil.com/pdf/network/bcc_bh_benefits.pdf.

Members are responsible for requesting preauthorization when preauthorization is required, although behavioral health providers or a member’s family member may request preauthorization on behalf of the member. All services must be medically necessary.

Inpatient and Alternative Levels of Care

Call the appropriate number on the back of the member’s ID card.

Outpatient

Members should call the behavioral health number on the back of their ID card.

Behavioral health professionals and physicians or the patient’s family, acting on behalf of the member, may call to request preauthorization.

For these outpatient services, preauthorization requires completion of a form located on the Forms page.

If ABA preauthorization is required, providers are to follow the protocol outlined in the Behavioral Health Outpatient Management Program page.

Inpatient and Alternative Levels of Care

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

Outpatient

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

• Partial Hospital Program (PHP)
• Outpatient Electroconvulsive Therapy (ECT)
• Repetitive Transcranial Magnetic Stimulation (rTMS)
• Psychological and Neuropsychological testing in some cases; BCBSIL would notify the provider if preauthorization is required for these testing services.

Behavioral Health Components for Government Programs

Information about the BH components for the BCBSIL Government Programs is available at the following links:

• Blue Cross Community Health Plans^SM (BCCHP^SM) - https://www.bcbsil.com/bcchp/benefits-coverage/behavioral-health-services.html
• Blue Cross Community MMAI (Medicare-Medicaid Plan)^SM - http://www.bcbsil.com/mmai/plan_details/behavioral_health.html

Prior Authorization for Government Programs
Information on prior authorization requirements for BCBSIL Government Programs is available at http://www.bcbsil.com/pdf/network/bcc_bh_benefits.pdf.

Behavioral Health Appointment Access Standards

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

• Initial Visit for Routine Care: Within 10 working days
• Follow-up for Routine Care: Within 30 calendar days
• Non-life threatening emergency: Within six (6) hours

BCBSIL is accountable for performance on national measures, like the Health Effectiveness Data Information Sets (HEDIS). Several of these measures specify expected timeframes for appointments with a BH professional. View our HEDIS tip sheets.

• Expectation that a member has a follow up appointment with a BH professional following a mental health inpatient admission within 7 and 30 days
• For members treated with Antidepressant Medication
  • Continuation of care for 12 weeks of continuous treatment (acute phase)
  • Continuation of care for 180 days (continuation phase)
• For children (6-12 years old) who are prescribed ADHD Medication
  • One follow up visit the first 30 days after medication dispensed (initiation phase)
  • At least 2 visits with provider in the first 270 days after initiation phase ends (continuation and maintenance phase)
• For members treated with a new diagnosis of alcohol or drug dependence
  • Treatment initiation through an inpatient admission, outpatient visit, intensive outpatient encounter or partial hospitalization program within 14 days following the diagnosis (initiation phase)
  • At least 2 visits/services, in addition to the treatment initiation encounter, within 30 days of initial diagnosis (encounter phase)

How to contact the BCBSIL Behavioral Health Unit:

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How to contact the BCCHP and MMAIBehavioral Health Unit:

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• Information on the Behavioral Health Care Management Program is located in the BCBSIL Provider Manual.*
• If you have any questions, please contact your assigned Provider Network Consultant.

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*This secure content is password protected. Refer to the instructions on the Secure Content Welcome page for details.

All behavioral health benefits are subject to the terms and conditions as listed in the member’s benefit plan.