Behavioral Health Utilization Management  - Requirements Update

In a letter dated October 28, 2009 Regence conveyed information regarding the Federal Mental Health Parity and Addiction Equity Act. That letter also contained information regarding changes to our behavioral health policy and utilization management requirements. Based upon feedback from our provider community, we have made the following changes:

• Prior authorization for more than one psychiatric diagnostic interview exam (CPT codes 90801 and 90802) per member, per provider, per year will not be required.
• Failure to submit a treatment plan prior to the 21st cumulative visit for outpatient or intensive mental health outpatient services or after the 8th week of chemical dependency intensive outpatient treatment will not result in automatic denial of coverage.
• A treatment plan from each behavioral health provider is required prior to the member’s 21st cumulative visit; however, it may not always be possible for a given provider to accurately identify the date of the 20th visit. Therefore, if a claim is received for a member who has utilized more than 20 visits, we will request an Outpatient Treatment Plan. We will not automatically deny claims if the treatment plan is not submitted prior to the 21st session. However, if the treatment plan is not received within 45 calendar days after it was requested, claims will reject for lack of clinical information to establish medical necessity. The provider has the right to appeal our decision, as detailed in the provider contract.
• The effective date for our new utilization management requirements, including those for outpatient and intensive outpatient services, detailed in our initial letter, remains February 1, 2010.
• Our new utilization management guidelines (PDF) apply to all group and individual products, not just those products subject to federal or state parity.
• In our initial letter, we indicated that the new federal mental health parity legislation does not apply to Federal Employee Program members, which is incorrect. The Federal Employee Program is subject to Federal Mental Health Parity. We appreciate the care you provide to our members and your continued support and participation in our networks.

If you have questions, please contact Regence Behavioral Health at 1(800) 780-7881, option 2.

2/8/2010

Federal Mental Health Parity and Addiction Equity Act

The Federal Mental Health Parity and Addiction Equity Act, effective October 3, 2009, prohibits health plans from placing more restrictive financial requirements or treatment limitations on mental health or substance use disorder benefits than on medical benefits. Beginning October 3, upon renewal of employer group plans with 51 or more employees, benefits for mental health or substance use disorders will be equal to medical benefits.

Type of service

Notification Upon Admission Required

Services Reviewed

Contact Number

Detoxification

Yes

Before day 3

1 (800) 780-7881

Inpatient chemical dependency

Yes

Before day 3

1 (800) 780-7881

Inpatient mental health

Yes

Before day 3

1 (800) 780-7881

Intensive outpatient mental health

No

Before visit 21*

1 (800) 780-7881

Intensive outpatient chemical dependency

Yes

After 8 weeks

1 (800) 780-7881

Outpatient chemical dependency

No

Before visit 21*

1 (800) 780-7881

Outpatient mental health

No

Before visit 21*

1 (800) 780-7881

Partial hospitalization chemical dependency

Yes

Before day 3

1 (800) 780-7881

Partial hospitalization mental health

Yes

Before day 3

1 (800) 780-7881

Residential chemical dependency

Yes

Before day 3

1 (800) 780-7881

Residential mental health

Yes

Before day 3

1 (800) 780-7881