New Pre-authorization Requirements from BCBSIL Effective January 2011

This is better than the previous BCBSIL plan but still calls for a lot of additional effort on the part of the therapist. I am concerned that all mental health services will tack on new pre-certification requirements.

New Pre-authorization Requirements from BCBSIL Effective January 2011

New Preauthorization Requirements

Effective January 2011, BCBSIL will manage behavioral health (behavioral/mental health and substance abuse/chemical dependency) services or all non-HMO members, replacing Magellan Health Services. Behavioral Health care management will be more integrated with our medical care management, allowing our clinical staff to better identify members that would benefit from co-management earlier. This change may result in improved outcomes, enhanced continuity of care, clinical efficiency, and reduced costs over time.

A key change in 2011 will be the requirement for members to preauthorize all outpatient visits for behavioral health services. members will be notified of their responsibility to preauthorize outpatient services. You may preauthorize on behalf of the member by calling the number on the back of the member’s ID card; however preauthorization will ultimately be the responsibility of the member.

Members may receive authorization for up to 10 outpatient visits to any behavioral health provider(s) without the need to submit medical records. Outpatient treatment request (OTR) forms. Please note, however, either the member or the provider will need to preauthorize with BCBSIL prior to the visits, and all outpatient behavioral health services must be deemed medically necessary as outlined in the member’s benefit booklet. Once the preauthorization is received a letter acknowledging the authorization will be mailed to the member and the behavioral health provider. All outpatient behavioral health visits scheduled after he 10th visit will require that you submit an OTR form. The OTR form can be submitted at any point prior to the 11th visit. You can call
BCBSIL with the required information using the number on the back of the member’s ID card.

Will the provider be reimbursed or outpatient services rendered if the member does not call
for reauthorization?
BCBSIL may request an OTR form from the provider to determine medical necessity prior to reimbursement. The member may be responsible for paying claims if services are deemed medically unnecessary.

What are the preauthorization requirements for intensive outpatient programs?
Preauthorization is required prior to the member beginning any of these services. Clinical information will be reviewed to determine medical necessity before authorization.

Transition of Established Patients
BCBSIL will work with all behavioral health professionals to limit the possibility for disruptions in patient care coordination
during this transition. You can use the same phone number on the back of the ember’s ID card for submitting treatment
plans, requesting preauthorization and continuity of care, asking customer service inquiries, and more.