Unit 4: Behavioral Health
Highmark Behavioral Health Services provides behavioral health medical management services for members enrolled in Highmark programs.
The key objectives of Highmark’s Behavioral Health Care Management Program are as follows:
- Ensure timely access to appropriate quality outpatient specialty services
- Encourage adherence to evidence-based treatment standards.
- Support behavioral health care needs of members in active treatment with primary care providers.
- Increase communication and coordination of care between primary care providers, psychiatrists, and other behavioral health professionals.
- Work closely with health care providers to coordinate all aspects of services for its members with both medical and behavioral health needs, especially members with chronic medical conditions complicated by conditions such as depression and anxiety.
Reminder: Verify Eligibility
To determine whether a member has behavioral health care coverage through Highmark and whether an authorization is required, always verify the member’s benefits prior to providing services. Eligibility and benefits can be verified via Availity® or the applicable HIPAA electronic transaction.
In addition, the member’s benefit program must provide the specific benefit for the service the member is to receive. If the member’s benefit program does not provide the benefit, the provider will not be reimbursed for the services.
Referrals to In-Network Providers
When recommending inpatient services, be sure that the member is to receive care from a provider who participates in the network associated with the member’s program and, when applicable, is in the highest benefit tier.
Timely Utilization Management Determinations
Highmark’s Behavioral Health Services department provides timely utilization management determinations for all members and providers. Each utilization management determination is handled in a manner consistent with the clinical urgency of the situation and with legal and regulatory compliance requirements.
Contact Information
When Availity® is not available and/or for medical management questions/issues that cannot be handled through Availity, Highmark Behavioral Health Services can be reached by calling the telephone number for your service area:
- Delaware (DE): 800-421-4577
- New York: 844-946-6264
- Pennsylvania (PA) Western & Northeastern Regions: 800-258-9808
- Pennsylvania (PA) Central & Southeastern Regions: 800-628-0816
- West Virginia (WV): 800-344-5245
- Fax for PA, DE, and WV: 877-650-6112
- Fax for NY: 833-581-1866
Delaware, Pennsylvania, and West Virginia Hours of Availability:
- Monday through Friday – 8:30 a.m. to 7 p.m.
- Saturday – 8:30 a.m. to 4:30 p.m. (limited staffing for urgent requests)
New York Hours of Availability:
- Monday-Friday – 8:15 a.m. to 5 p.m.
- After hours: When utilization management is called outside of normal availability, a prompt is available to speak to a nurse. If the prompt is selected the call will be forwarded to an On-Call Service called Answer Phone.
Important! Privacy Reminder
When calling a behavioral health care manager directly, your call may be answered by voicemail. To uphold a member’s right to privacy and in consideration of HIPAA regulations and the importance of documentation, please do not leave clinical information about members on voicemail.
Consent Required for Release of Treatment Information
Providers are reminded that under federal and state laws, providers of mental health and substance abuse treatment services may be required to obtain members’ written authorization to release certain mental health and substance abuse treatment information to insurers and/or to other health care providers for the management of patient care.
As a contracted provider, it is your responsibility to obtain appropriate consent for release of information.
Restrictions for Substance Abuse Treatment
Pennsylvania Administrative Code Subsection 255.5(b) limits the information providers can release to insurers and/or other providers about substance abuse treatment, even with member written consent. Providers practicing in Pennsylvania are advised to ensure that the information they communicate to Highmark Behavioral Health Services is compliant with these regulations.
When practicing in any of Highmark’s service areas, contracted providers are expected to be compliant with any applicable federal or state regulations.
For More Information
For additional information for providing behavioral health services to Highmark members, please see Chapter 4 Unit 2: Behavioral Health Providers.
Basis of Authorization Decisions
Highmark Behavioral Health Services bases its decisions to authorize care upon the following:
- Clinical information available to the care manager or physician reviewer at the time of review
- The safety of the patient and, when applicable, the safety of others
- Availability of other effective but less restrictive treatment settings
- Availability to the member of the appropriate behavioral health benefit
- Application of the appropriate medical necessity criteria
Medically Necessary Definition
Except where any applicable law, regulation, or government body requires a different definition (i.e., the Federal Employees Health Benefits Program, Children’s Health Insurance Program [CHIP], Centers for Medicare & Medicaid Services [CMS] as to the Medicare Advantage program, etc.), Highmark has adopted a universal definition of medical necessity:
The term medically necessary, medical necessity, or such other comparable term shall mean health care services or supplies that a provider, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing, or treating an illness, injury, disease, or its symptoms, and that are:
a. In accordance with generally accepted standards of medical practice; and
b. Clinically appropriate, in terms of type, frequency, extent, site, and duration, and considered effective for the patient’s illness, injury, or disease; and
c. Not primarily for the convenience of the patient, physician, or other health care provider, and not more costly than an alternative service, sequence of services, or site of service at least as likely to produce equivalent therapeutic or diagnostic results given the nature of the patient’s diagnosis, treatment, illness, injury, or disease, the severity of the patient’s symptoms, or other clinical criteria.
For these purposes, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, Specialty Society recommendations, and the views of providers practicing in relevant clinical areas and any other relevant factors.
Medical Necessity Criteria for Substance Abuse Treatment
Highmark's Behavioral Health Services department uses the current version of the American Society of Addiction Medicine (ASAM) criteria when reviewing the medical necessity of substance abuse treatment.
Copies of these criteria can be purchased by visiting the ASAM website, or by contacting ASAM at 301-656-3920.
Medical Necessity Criteria for Substance Abuse Treatment
NYS Office of Addition Services and Supports (OASAS), in partnership with National Center on Addiction and Substance Abuse at Columbia University (CASA Columbia), developed the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0, a web-based tool, to assist substance abuse treatment providers, Medicaid Managed Care plans, and other referral sources in determining the most appropriate level of care (LOC) for a client with a substance use disorder and/or problem gambling disorder. This tool enables the referral source to identify the most appropriate treatment setting closest to the client's community.
Medical Necessity Criteria for All Other Behavioral Health Services
Highmark's Behavioral Health Services department applies MCG Care Guidelines in DE, PA, and WV and InterQual Criteria in NY for Behavioral Health when reviewing the medical necessity of behavioral health services.
Facilities are able to view the MCG Care Guidelines/InterQual Criteria in Predictal, which is accessible via Availity. If for any reason Availity and/or Predictal is not available, facilities can call Highmark Behavioral Health Services for medical necessity criteria applicable to a particular case.
Criteria Reviewed Annually
All criteria are reviewed, approved, and/or revised at least once annually by the Care Management Committee (CMC). The CMC is comprised of practicing physicians in the community and in hospital administrative positions, including psychiatrists, who are involved in care management functions.
Prudent Layperson Laws for Emergency Services
Highmark adheres to state “prudent layperson” laws which require payment of benefits for mental health services in the event of an emergency under prudent layperson laws. An emergency department physician can make a decision regarding admission or physical or chemical restraints.
Highmark adheres to state “prudent layperson” laws which require payment of benefits for mental health services in the event of an emergency under prudent layperson laws. An emergency department physician can make a decision regarding admission or physical or chemical restraints.
Highmark agrees that where a physician has not entered into a different agreement with Highmark or the hospital or other mental health care facility where services are rendered, and where Highmark has not entered into a different agreement with such hospital or mental health care facility, in the event of an emergency, Highmark will pay for medically necessary emergency care mental health covered services provided by such physician in accordance with applicable prudent laypersons standards, the definition of medical necessity as defined above, and the terms and conditions of the plan member’s plan and Highmark will pay for medically necessary mental health covered services provided by physicians resulting from the admission in accordance with the definition of medical necessity and the terms and conditions of the member’s plan.
Behavioral Health Authorization
Authorization (or “preauthorization”) is the process whereby the behavioral health provider must contact Highmark Behavioral Health Services to determine the eligibility of coverage for and/or the medical necessity or appropriateness of behavioral health services.
Inpatient Services
For most Highmark products, authorization is required to receive coverage for all inpatient behavioral health services, or “higher levels of care.” The term “higher levels of care” applies to the levels listed below:
- Inpatient mental health services
- Inpatient detoxification services
- Inpatient rehabilitation (substance abuse treatment and mental health treatment)
Although authorization is not required for emergency services, an authorization is required if an emergency service results in an inpatient admission.
Inpatient Psychiatric Admissions for Under Age 18
No preauthorization or concurrent review is required for the initial 14 days of medically necessary inpatient psychiatric admissions for those who have not yet reached the age of 18, in a facility that is licensed by the NY State Office of Mental Health and is participating in the Blue Cross Blue Shield network. Although preauthorization is not required, facilities are required to provide the health plan with notification of the admission, and the initial treatment plan, within two business days of admission and participate in periodic consultation with the plan.
- If the facility fails to notify the health plan of either the inpatient admission or the initial treatment plan within two business days of the admission, the health plan may begin concurrent review immediately upon learning of the admission, even if it is during the initial 14 day period.
- All care may be reviewed retrospectively and may be denied if not medically necessary. If coverage is denied retrospectively, the member is held financially harmless, except for allowable co-pay and deductible amounts.
New York State Opioid Legislation SUD/OUD Inpatient/Facility Admissions
No preauthorization or concurrent review is required for the initial 28 days of medically necessary inpatient treatment for Substance Use Disorder/Opioid Use Disorder (SUD/OUD) in New York State Office of Alcoholism and Substance Abuse Services (OASAS) licensed facilities that are participating in the Blue Cross Blue Shield network.
Levels of care include detoxification, inpatient rehabilitation, and residential treatment. Although preauthorization is not required, facilities are required to provide the health plan with notification of the admission and the initial treatment plan within two business days of admission.
- The facility is also required to perform daily clinical review, including “periodic consultation” with the plan to ensure the facility is using the OASAS Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) tool.
- If the facility fails to notify the health plan of either the inpatient admission or the initial treatment plan within two business days of the admission, the health plan may begin concurrent review immediately upon learning of the admission, even if it is during the initial 28-day period.
- All care may be reviewed retrospectively and may be denied if not medically necessary. If coverage is denied retrospectively, the member is held financially harmless, except for allowable co-pay and deductible amounts.
Request for Inpatient SUD/OUD prior to discharge from inpatient admission.
The Plan will make a determination regarding a request for inpatient SUD/OUD treatment within 24 hours of receiving the request (if required per contract), provided the request is submitted to the Utilization Review (UR) agent at least 24 hours before discharge from the inpatient admission.
The Plan will provide coverage for the inpatient treatment while the determination is pending. Expedited review process is not limited to discharges from an inpatient hospital, and applies to all inpatient facilities, transfers between, and continued stay requests covered under the contract.
Making A Determination of Coverage Based on Medical Necessity
When making a determination of coverage based on medical necessity, Highmark considers the following factors when applying criteria to a given individual:
- Age
- Co‐morbidities
- Complications including risk factors and functional status
- Progress of treatment
- Psychosocial factors
- Home environment/availability and adequacy of supports (when applicable)
Highmark also considers characteristics of the local delivery system that are available for the member, such as the availability of inpatient rehabilitation, residential treatment facilities, outpatient services, or home care and community supports in the service area to support the member after discharge.
If medical necessity criteria fail at the primary review, a secondary review with a Highmark Medical Director is required. Additional information is obtained and provided to the Medical Director for second level review with consideration of:
- Whether or not support systems are local and accessible/adequate to meet member/parent-child needs
- Availability of stable housing/homelessness
- Living environment, changes in job/school, domestic violence, high-risk drug use, illegal or unsanitary conditions
- Prior attempts at living independently
- Recent death or health status of immediate family member or caretaker
- Prior treatment history including episodes of care, successful treatment episodes, impulse control, and ability to self-manage
- Member/caregiver engagement and acceptance, understanding of illness and functional limitation, participation in treatment and recovery plan, ability to assist/implement interventions, and acceptance of own responsibility to participate in recovery process
Important! Exceptions
For important changes in Delaware legislation affecting authorization requirements for drug and alcohol dependency treatment in Delaware, please see the next section of this unit.
If Authorization is Not Obtained
When the behavioral health provider is required to obtain authorization but provides covered services without obtaining authorization, the member will not be responsible for payment.
Policy
Per Delaware legislation (Del. Code tit. 18 §§ 3343, 3578), Highmark Blue Cross Blue Shield Delaware may not impose precertification, prior authorization, pre-admission screening, or referral requirements for the diagnosis and medically necessary treatment, including inpatient, of drug and alcohol dependencies at a Highmark Delaware network participating facility.
Definition
Drug and alcohol dependencies are defined as a substance abuse disorder or the chronic, habitual, regular, or recurrent use of alcohol, inhalants, or controlled substances as identified in Chapter 47 of Title 16 of the Delaware Code.
Concurrent Utilization Review
Concurrent utilization review is prohibited during the first 14 days of medically necessary inpatient and residential treatment by a network participating facility approved by a nationally recognized health care accrediting organization or the Division of Substance Abuse and Mental Health; 30 days of Intensive Outpatient Program treatment; or five days of inpatient withdrawal management, provided that the facility notifies Highmark Delaware of both the admission and the initial treatment plan within 48 hours of the admission.
The facility must perform daily clinical review and periodically consult with Highmark Delaware to ensure that the facility is using the evidence-based and peer reviewed clinical review tool used by Highmark Delaware and designated by the American Society of Addiction Medicine (ASAM) or, if applicable, any state-specific ASAM criteria, and appropriate to the age of the patient to ensure that the inpatient treatment is medically necessary for the patient.
Retrospective Review
Highmark Delaware may perform retrospective review for medical necessity and appropriateness of all services provided during an inpatient stay or residential treatment, including the initial 14 days of treatment; 30 days of Intensive Outpatient Program treatment; or five days of inpatient withdrawal management.
Highmark Delaware may deny coverage for any portion of the initial 14-day inpatient or residential treatment on the basis that the treatment was not medically necessary only if the treatment was contrary to the evidence-based and peer reviewed clinical review tool used by Highmark Delaware and designated by ASAM or any state-specific ASAM criteria.
Applicability
These statutes are applicable to all Highmark Delaware fully insured individual and group health benefit plans. Self-insured employer groups will be offered the opportunity to adopt the mandate and may or may not elect to follow the mandate. Medicare supplemental plans are exempt from this law.
Member Liability
The Highmark Delaware member does not have any financial obligation to the facility for inpatient and residential treatment other than any applicable copayments, coinsurance, or deductible amounts required under their benefit plan.
For More Information
For additional information on this mandate, please see Highmark's Provider Manual Chapter 4 Unit 2: Behavioral Health Providers.
Provider-Driven Process
Authorization of behavioral health services is a provider-driven process. This means that it is the provider’s responsibility to obtain the required authorization for all behavioral health services.
In the absence of required authorizations, claims for behavioral health services are not reimbursed and the member must be held harmless.
Complete Clinical Assessment Prior To Initiating Authorization Request
Before initiating the authorization request (either via Availity® or through telephone contact with Highmark Behavioral Health Services), please complete the clinical assessment and be prepared to provide the information below:
- The member’s name and ID number, including alpha prefix
- The events precipitating the call
- The member’s symptoms and mental status
- The degree of impairment in function
- The potential for harm to self and/or others
- The degree of distress
- The member’s treatment history, including medications
- Axis I-III Diagnoses
- The treatment plan or suggested treatment plan
Authorization Request Submission Required
Authorization requests must be submitted through Highmark’s provider portal, Availity®, for the following behavioral health services:
- Inpatient Admissions
- Inpatient Transfers
Requests for authorization of inpatient behavioral health services are submitted via Availity® by the facility providing services. However, if Availity is unavailable or the facility is not Availity-enabled, authorization reviews can be initiated by calling Highmark Behavioral Health Services at 800-258-9808 or faxing 877-650-6112.
Time Frames for Review
Highmark Behavioral Health Services renders authorization decisions within the time frames required by law and the applicable regulatory agencies. For a routine review, Highmark Behavioral Health Services will render a decision within two business days from the receipt of the request.
Important! New York Behavioral Health Services will have three business days from the receipt of the request to render a decision.
Medical Necessity Criteria Used
In making authorization decisions, the Highmark behavioral health care manager reviews the information submitted and makes a determination based on the medical necessity criteria.
If Criteria Are Met
If the medical necessity criteria are met, an internal Highmark system authorization is generated, as well as a notification to the provider.
- If providers are Availity®-enabled, they can retrieve the authorization notice by accessing Predictal. (Select the authorization in question to view it.)
- If providers are not Availity-enabled, the authorization notice is sent to the provider as a letter through U.S. Mail, with a copy to the member. (The exception to this process is that Medicare Advantage members do not receive a copy of the letter.)
If Criteria Are Not Met
If the behavioral health care manager determines that the criteria have not been met, he or she may recommend alternative levels of care and treatment options for which the criteria have been met.
If no alternative level of care can be arranged, the case is sent to a Highmark physician reviewer. The physician reviews the clinical information and has the option to contact the attending provider (or designee) to discuss the case. The physician reviewer then renders a decision.
If the decision is made to not authorize the requested care, a verbal nonauthorization notice is given to the provider. A written notice follows within one business day after the verbal notice. Information about appeal rights is also communicated.
Peer-To-Peer Conversation
If the treating or ordering provider did not have an opportunity to discuss a case with the clinical peer reviewer before a utilization management decision was made, he or she may request a peer-to-peer conversation after the decision has been rendered for a commercial member.
To initiate the request, the provider should call the dedicated peer-to-peer tollfree phone number: 866-634-6468. Hours of operation are from 8:30 a.m. to 4:30 p.m. (EST), Monday through Friday (except in New York where you can call from 8:15 a.m. until 5:00 p.m.). A live agent will take the necessary information and forward the request to a Highmark clinical peer reviewer.
If an emergent need arises before or after business hours, the option to leave a voicemail message is available. The following information will be needed:
- CASE/REQ# (e.g., REQ-1234).
- Patient’s name and Member ID.
- Name of the treating and/or ordering provider requesting the peer-to-peer conversation and the phone number where a Highmark clinical peer reviewer can reach the provider.
The clinical peer reviewer who made the determination (or an appropriate designee) will contact the provider within one business day to discuss the case. If the provider still does not agree with the non-authorization decision after the peer-to-peer conversation, an appeal can be initiated.
Note: The peer-to-peer conversation option is not available for Medicare Advantage members.
Appeal of Adverse Decisions
Attending providers and facilities can appeal a utilization management decision that results in non-authorization of reimbursement for health care services. Please see Chapter 5 Unit 5: Denials, Grievances, and Appeals for more information on appeal rights
Concurrent review, also known as continued stay review, is an assessment that determines medical necessity and appropriateness for an extension of previously authorized services.
Plan-Specific Requirements
The need for concurrent review of higher levels of care varies based on the product and the specific benefit plan under which the member has coverage. As for all behavioral health services, always verify plan-specific requirements via Availity®, or by contacting Highmark Behavioral Health Services.
When is Review Completed?
Concurrent reviews for behavioral health services must be completed on or before the "Last Covered Day" (LCD) of the previous authorization.
Time Frames
Concurrent review decisions for behavioral health services are communicated to the provider within one business day, or no later than 24 hours, from receipt of the request.
In view of the short turnaround time imposed by regulating bodies, providers are reminded to forward all relevant clinical information as quickly as possible to avoid denials based on lack of clinical data.
Who Initiates?
The provider is ultimately responsible for initiating the concurrent review process; however, it can be initiated by the behavioral health care manager as well.
Initiating the Review
Concurrent review requests for inpatient care are normally submitted via Availity® (Availity can be used even if the original case was initiated by telephone contact with Highmark Behavioral Health Services). However, if Availity is unavailable or the facility is not Availity-enabled, concurrent reviews can be initiated by calling Highmark Behavioral Health Services.
When preparing for a concurrent review dialogue with the behavioral health care manager, please plan to provide clinical information that is new or updated since the previous review or authorization.
Types of Information to be Provided
The information below should be provided to the behavioral health care manager for a concurrent review:
- Presenting problem/proximal event
- Current mental status
- Progress since the last review
- Barriers to progress and modifications to the treatment plan
- Psychiatric and substance abuse history and response
- Current substance abuse
- Vital signs, withdrawal, blood alcohol level
- Axis I-V diagnosis
- Family/social support involvement since last review
- Risk related to functional impairment/inadequate support system
- Risk related to self and/or others
- Medications, including start date, dosage, and frequency, as well as PRN medications ordered and given
- Current medical status, complications, consultations, medications, plans of care
- Treatment plan addressing targeted symptoms
- Treatment plan changes based on progress or newly identified problems
- Patient response to and compliance with treatment
- Coordination of care for patients with co-existing medical and/or substance-related disorders
- Discharge planning, including scheduling of appointments
- Any additional assistance needed
- Any other information which may be useful in assessing the medical necessity of the patient’s continuing to remain at this level of care
Important! Privacy Reminder
When working directly with a particular behavioral health care manager, it is possible that a provider may occasionally reach a voicemail line. In consideration of the member’s right to privacy and the importance of documentation, you are asked to never leave clinical information about your patient on the voicemail system.
Compliance
Information for concurrent review should be provided in accordance with the limits imposed by federal or state law, including but not limited to Pennsylvania Administrative Code Subsection 255.5(b).
Outcomes of the Decision Process
After all the relevant clinical information has been gathered, the behavioral health care manager will make a clinical determination based on the appropriate medical necessity criteria.
- If criteria are still met, the continued stay may be authorized.
- If criteria are not met, an alternative level of care may be discussed.
- If criteria are not met and an alternative level of care is not accepted, the case is referred to the physician reviewer. The physician reviewer then contacts the attending provider. A decision will be rendered within the appropriate time frame based on the urgency of the request.
Medicare Advantage: When Continued Stay is Not Approved
The Centers for Medicare & Medicaid Services (CMS) requires the issuance of the Important Message From Medicare (“Important Message”) to the Medicare Advantage patient within two days of admission as well as a follow-up notice again prior to discharge. This Important Message explains the member’s rights as an inpatient as well as his or her right to appeal a discharge decision.
When a concurrent review results in a denial and a Medicare Advantage member disagrees with the decision to discharge him or her from inpatient care, the member may request a review as instructed in the Important Message. Highmark delegates responsibility to the facility to then issue the required Detailed Notice of Discharge (“Detailed Notice”) form to the member. This form gives a detailed explanation of the discharge decision as well as a description of any applicable Medicare and/or Medicare Advantage coverage rules, policies, or rationales which support the decision.
Note: For more information about the Important Message and Detailed Notice requirements for Medicare Advantage members, please see Chapter 5 Unit 3: Medicare Advantage Procedures.
A retrospective review, also known as post-service review, is an evaluation of the medical necessity and appropriateness of services after they have been provided.
Information Needed
To demonstrate that the treatment that had been provided was medically necessary, Highmark Behavioral Health Services will need the same type of information as that required for a concurrent review.
Note: For a list of the specific types of information needed for both the concurrent and retrospective reviews, please see the preceding content regarding concurrent review.
Compliance
When requesting a retrospective review of substance abuse treatment services, please provide information regarding the member’s substance abuse history in a manner compliant with Pennsylvania Administrative Code 255.5.
Mailing Address
Information for retrospective reviews of mental health or substance abuse treatment services can be mailed to the addresses below.
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Delaware, Pennsylvania, and West Virginia |
New York |
|---|---|
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Retro Reviews/Standard Commercial Appeals: Utilization Management P.O. Box 890392 Camp Hill, PA 17089-0392 |
Utilization Management Appeals Unit P.O. Box 4208 Buffalo, NY 14240-4208 |
Note: This address is also to be used for behavioral health retrospective review requests for Federal Employee Program (FEP) members.
Outcomes of the Decision Process
After all the relevant clinical information has been gathered, the behavioral health care manager will make a clinical determination, based on the appropriate medical necessity criteria, on the services provided prior to notification or without authorization.
- If criteria are met, an authorization is issued.
- If criteria are not met, the case is referred to a physician reviewer.
Review Results in Approval
If an authorization is issued, the rendering provider can obtain the authorization number from Predictal, which is accessible via Availity®. To have a previously denied claim adjusted, the provider can then open a Secure Message, reporting the newly obtained authorization number. Providers who are not Availity-enabled can call the Highmark Provider Service Center for your service area to request the adjustment with the new authorization number.
Non-Authorization Decision
When it is determined that a member’s case does not meet medical necessity criteria, alternative levels of care may be discussed. If these suggestions are not acceptable to the provider or facility, the case is sent to a physician reviewer.
If the physician reviewer makes a decision to not authorize the requested services, a verbal non-authorization notice is given to the provider or facility, and a written notice follows within the required time frames. The applicable appeal rights are provided both verbally and in writing.
Peer-to-Peer Conversation
If the treating or ordering provider did not have an opportunity to discuss the case with the clinical peer reviewer before a utilization management decision was made, he or she may request a peer-to-peer conversation for commercial members (the peer-to-peer option is not available for Medicare Advantage members).
To initiate the request, the provider should call the dedicated peer-to-peer phone line: 866-634-6468. A live agent will take the necessary information and forward the request to a Highmark clinical peer reviewer.
Delaware, Pennsylvania, and West Virginia Hours of Operation:
- Monday through Friday from 8:30 a.m. to 4:30 p.m. (EST)
- After business hours: If an emergent need arises before or after business hours, the option to leave a voicemail message is available. The following information will be needed:
- Patient’s name and Member ID.
- Name of the treating and/or ordering provider requesting the peer-to-peer conversation and the phone number where a Highmark clinical peer reviewer can reach the provider.
- Patient’s name and Member ID.
New York Hours of Operation:
- Monday through Friday from 8:15 a.m. to 5 p.m. (EST)
The clinical peer reviewer who made the determination (or an appropriate designee) will contact the provider within one business day to discuss the case. If the provider still does not agree with the non-authorization decision after the peer-to-peer conversation, an appeal can be initiated.
Note: If the provider chooses to proceed with an appeal, the peer-to-peer option is forfeited and no longer available to the provider.
Initiating An Appeal
Either the attending provider or the facility may initiate an appeal verbally or in writing at the time of the initial non-authorization decision.
When requesting a provider appeal, the provider or facility should provide the name and telephone number of the individual who will be able to discuss the clinical aspects of the case with the physician reviewer.
Two types of appeals are available for providers of behavioral health services -- expedited appeals and standard appeals
Expedited Appeals (DE, PA, WV)
An expedited behavioral health provider appeal is a formal appeal of a decision denying one of the following on the basis of medical necessity:
- An imminent or ongoing service; or
- The admission or continued stay of a patient who has received emergency services but has not been discharged from a facility.
Expedited Appeals (NY)
Eligibility for an Expedited Appeal process is available to members appealing adverse determinations involving:
- Continued or extended health care services.
- Procedures, treatments, or additional services for a member undergoing a course of continued treatment prescribed by a health care provider.
- Situations in which a health care provider believes an immediate appeal is warranted, except post service adverse determinations.
- Any situation that would increase risk to the member's health.
- Denial for home health care services following a discharge from a hospital admission.
If Blue Cross Blue Shield requires information necessary to conduct an expedited appeal, Blue Cross Blue Shield shall immediately notify the member and the member's health care provider by telephone or fax to identify and request the necessary information followed by written notification. The clinical peer reviewer will be available within one business day, or sooner.
Time Frame: Expedited Appeals
For an expedited appeal, a decision is rendered within one business day of receipt of complete information, not to exceed 72 hours of receipt of the request.
Note: For Pennsylvania Act 68 expedited appeals, the decision time frame is not to exceed 48 hours. Please refer to Chapter 5 Unit 5: Denials, Grievances, and Appeals, section titled "Expedited Grievance: Filing On Behalf of a Member (PA Act 68)," for additional information.
Potential Outcomes of The Expedited Appeal
Either of the following could occur as the outcome of an expedited appeal:
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If ... |
Then ... |
|---|---|
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The denial is overturned upon expedited appeal, |
an authorization is provided for the service. |
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The denial is upheld upon expedited appeal, |
a statement of appeal rights is provided, both verbally and in writing. The provider can request a standard appeal. |
Standard Provider Appeals
A standard behavioral health provider appeal is a formal appeal of a denial decision that does not meet the criteria for an expedited appeal.
It is also used as a secondary appeal level when a denial is upheld under the expedited appeal process.
As is necessary for an expedited appeal, the facility must provide the name and telephone number of the facility contact who will be prepared to discuss the clinical aspects of the case with a physician reviewer for a standard provider appeal.
Time Frame: Standard Provider Appeals
For a standard provider appeal, a decision is rendered and communicated in writing within 30 days of receipt of the request.
Potential Outcomes of Standard Appeal Process
Either of the following could occur as a result of the standard appeal process:
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If ... |
Then ... |
|---|---|
|
The denial is overturned at standard appeal, |
an authorization is provided. |
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The denial is upheld at standard appeal, |
the decision is final, no further appeals can be initiated. |
Appealing on Behalf of A Member
Upon request by the member or the member’s family, a facility may file an appeal on behalf of a member as his or her representative.
If appealing on behalf of the member, the facility must provide Highmark with the name and address of the facility and a written consent form signed by the member, which specifies the services to be performed. A copy of the appropriate form is attached to every denial letter.
Note: For more detailed information about appealing on behalf of a member, please see Highmark's Provider Manual Chapter 5 Unit 5: Denials, Grievances, and Appeals.
Discharge planning should begin prior to or upon admission to an inpatient facility. At the time of precertification, the behavioral health care manager discusses discharge planning barriers and assists with any discharge needs.
Encourage Follow-Up Appointment
To increase the likelihood that a member being discharged from inpatient behavioral health services will receive appropriate aftercare, it is very important that the member leave the hospital with a follow-up outpatient appointment.
Contact Following Discharge
Upon a mental health inpatient discharge, a Highmark behavioral health specialist will attempt to make a post-discharge call to the member. When post-discharge contact is made, the behavioral health specialist will verify that a follow-up appointment has been made or, if necessary, assist the member in obtaining an appointment.
The behavioral health specialist will provide education about the importance of adhering to scheduled appointments and will work with the member to resolve any barriers. They will also discuss any questions the member may have regarding discharge instructions, medication changes, and/or any other issues of concern to the member.
Continuing Care Coordination
Highmark Behavioral Health Services is committed to working with providers to support members in maintaining the gains achieved during inpatient treatment.
It is very important that the member leaves the facility having scheduled a follow-up appointment with a psychiatrist or other behavioral health provider within seven days post-discharge. If the appointment was not kept, the behavioral health specialist will work with the member to resolve any barriers and assist in rescheduling the appointment.
When Medication is Prescribed
The follow-up appointment is particularly important when a patient is discharged with a prescription for psychotropic medication. Follow-up care should be arranged with a behavioral health provider.
Discharge Summary
Facilities are reminded to complete the Discharge Summary Fax Template at, or immediately following, discharge of a Highmark member from inpatient behavioral health care admission.
Special Requirements for Medicare Advantage Members
The Centers for Medicare & Medicaid Services (CMS) requires that people with coverage under traditional Medicare or a Medicare Advantage plan to be fully aware of their right to appeal a discharge decision. Therefore, a special process applies to these members. This process begins when a Medicare Advantage member is admitted to an inpatient level of care and requires additional action prior to discharge.
Note: For information on these special requirements for Medicare Advantage members, please see Chapter 5 Unit 3: Medicare Advantage Procedures.
The following entities, which serve the noted regions, are independent licensees of the Blue Cross Blue Shield Association: Western and Northeastern PA: Highmark Inc. d/b/a Highmark Blue Cross Blue Shield, Highmark Choice Company, Highmark Health Insurance Company, Highmark Coverage Advantage Inc., Highmark Benefits Group Inc., First Priority Health, First Priority Life or Highmark Senior Health Company. Central and Southeastern PA: Highmark Inc. d/b/a Highmark Blue Shield, Highmark Benefits Group Inc., Highmark Health Insurance Company, Highmark Choice Company or Highmark Senior Health Company. Delaware: Highmark BCBSD Inc. d/b/a Highmark Blue Cross Blue Shield. West Virginia: Highmark West Virginia Inc. d/b/a Highmark Blue Cross Blue Shield, Highmark Health Insurance Company or Highmark Senior Solutions Company. Western NY: Highmark Western and Northeastern New York Inc. d/b/a Highmark Blue Cross Blue Shield. Northeastern NY: Highmark Western and Northeastern New York Inc. d/b/a Highmark Blue Shield.
All references to “Highmark” in this document are references to the Highmark company that is providing the member’s health benefits or health benefit administration and/or to one or more of its affiliated Blue companies.
All revisions to this Highmark Provider Manual (the “manual” or “Highmark Provider Manual”) are controlled electronically. All paper copies and screen prints are considered uncontrolled and should not be relied upon for any purpose.
