Medica Behavioral Health - MN CAC Authorization Requirements Optum Behavioral Solutions Effective: 10/01/2016

Transcription

1 Medica Behavioral Health - MN CAC Authorization Requirements Optum Behavioral Solutions Effective: 10/01/2016 Medicaid Products: Medicare Products: Commercial Products: PMAP, MNCare, MSC+, MSHO (Dual Solution), SNBC (AccessAbility Solution) Prime Solutions, Select Solutions Fully and Self Insured Group Plans Level of Care Adult Rehabilitative Mental Health Services (ARMHS) **Functional for select providers may require authorization due to contract **Excludes assessments for Autism, Eating Disorders and Treatment** for Autism, Eating Disorders and Treatment Authorization Requirements for Medicaid Products: Contracted for Level of Care Non-Contracted Mental Health Substance Use Disorder Mental Health and Substance Use Disorder Medicaid products do not have Out-of-Network benefits. The member is required to use a Medica Behavioral Health network provider to receive services. If a member needs a covered service that cannot be received from a Plan network provider, authorization from Medica Behavioral Health to see an Out-of- Network provider is required. Assertive Community Treatment (ACT) Autism Services Behavioral Health Homes Certified by DHS Biofeedback Children s Residential Rule 5 Exceptions: Authorization is NOT required for Out-of- Network ARMHS and CTSS services. Children s Therapeutic Services and Supports (CTSS) BH Page 1

2 Crisis Residential Crisis Response Services **Includes Mobile Crisis Detox - Community Based Residential Detox/Ambulatory Detox Detox - Inpatient Hospital Based Eating Disorder Services Electro-Convulsive Therapy Evaluation/Management Services Health and Behavioral Assessment ** In-Home Therapy Services Inpatient Intensive Community Based Services (ICBS) **Does not include ICBS Intensive Outpatient Services (IOP) **Including DBT** **Services for Eating Disorders and Autism Require Authorization** Intensive Residential Treatment Services (IRTS) Mental Health Therapy Outpatient Services **Includes, but not limited to **Excluding Assessment** Page 2

3 Neuropsychological Testing Observation Bed/Hours Opioid Treatment Other than Partial Hospitalization Psychological Testing Residential SNBC Care Coordination **Eligible only for Group Numbers and 05064** Substance Abuse Outpatient Services (H2035/H2035 HQ) Targeted Case Management (TCM) Telemedicine/Telehealth **Refer to Medica s Coverage Policy Telephonic Evaluation ** Travel **Only in Conjunction with Covered Treatment Services** Page 3

4 Level of Care **Excludes assessments for Eating Disorders Treatment** for Eating Disorder Treatment Authorization Requirements for Medicare Products: Providers must be Medicare Eligible Contracted for Level of Care and Medicare Eligible Non-Contracted Mental Health Substance Use Disorder Mental Health and Substance Use Disorders If out-of-network providers are used to obtain services, the services are covered under Original Medicare. Out-of-Network Providers bill Medicare as the Primary. Member is liable for Patient Responsibility such as coinsurance when Medicare pays as Primary. Biofeedback Crisis Response Services **Includes Mobile Crisis Crisis Residential Detox - Inpatient Hospital Based Detox - Community Based Residential Detox/Ambulatory Detox Dietician Services for Eating Disorders Eating Disorder Services Electro-Convulsive Therapy Evaluation/Management Services Health and Behavioral Assessment ** Inpatient Hospital Based Facilities Page 4

5 Residential Medicare Eligible Hospital Based Facilities Partial Hospitalization Intensive Outpatient Services **Allowed under Prime Solutions Product, though not covered under standard Medicare benefits - This includes DBT. **Services for Eating Disorders Require Authorization** **IOP is NOT available under Select Solutions Observation Bed rtms Substance Use Disorder Outpatient Services (H2035/H2035 HQ) Mental Health Outpatient Therapy Services **Includes, but not limited to Neuropsychological Testing Observation Bed Opioid Treatment Other than Psychological Testing Telemedicine/Telehealth **Refer to Medica s Coverage Policy Telephonic Evaluation ** Travel Page 5

6 Authorization Requirements for Commercial Products: 5 Digit Groups Only Please call for benefits to determine authorization requirements for 6 digit group numbers. Level of Care Contracted for Level of Care Non-Contracted: Out-of-Network Benefits Apply **Excludes assessments for Autism, Eating Disorders and Treatment** for Autism, Eating Disorders and Treatment Mental Health Substance Use Disorder Mental Health and Substance Use Disorders Autism Services Biofeedback Crisis Response Services **Includes Mobile Crisis Crisis Residential Detox - Community Based Residential Detox/Ambulatory Detox Detox - Inpatient Hospital Based Eating Disorder Services Electro-Convulsive Therapy Evaluation/Management Services Health and Behavioral Assessment ** In-Home Therapy Services Page 6

7 Inpatient Intensive Community Based Services (ICBS) **Does not include ICBS Intensive Outpatient Services **Including DBT** **Services for Eating Disorders and Autism Require Authorization** Mental Health Outpatient Therapy Services **Includes, but not limited to **Excluding Assessment** Neuropsychological Testing Observation Bed/Hours Opioid Treatment Other than Partial Hospitalization Psychological Testing Residential Substance Use Disorder Outpatient Services (H2035/H2035 HQ) Telemedicine/Telehealth **Refer to Medica s Coverage Policy Telephonic Evaluation ** Travel Page 7