June 2010
Behavioral Health utilization management requirements update
In a letter dated March 3, Asuris conveyed information regarding the Federal Mental Health Parity and Addiction Equity Act and changes to our behavioral health policy and utilization management requirements. Based upon your feedback, we have made the following changes:
- Prior authorization for more than one psychiatric diagnostic interview exam (CPT 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. 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 agreement.
The effective date for our new utilization management requirements, including those for outpatient and intensive outpatient services, detailed in our initial letter, remains June 5.
Our utilization management requirements apply to all group and Individual products, not only to those products subject to federal or state parity.
If you have questions, please contact Asuris Behavioral Health.