The Behavioral Health Program has been established to assist in the administration of Mental Illness and Substance Use Disorder Rehabilitation Treatment benefits, including utilization management and case management programs. The Behavioral Health Program is primarily staffed with Physicians, Psychologists, Clinical Professional Counselors, Clinical Social Workers, Marriage and Family Therapists and registered nurses.
PREAUTHORIZATION REQUIREMENTS
Failure to contact Blue Cross and Blue Shield may result in a reduction of benefits. These reductions in benefits are in addition to the applicable Copayments, Coinsurance, deductibles and out-of-pocket amounts that are your responsibility under this Certificate. Providers may bill you for any reduction in payment resulting from failure to contact Blue Cross and Blue Shield.
You are encouraged to call ahead if the availability of payment under this Certificate is important to your decision to receive care. Blue Cross and Blue Shield may be reached twenty‐four (24) hours a day, 7 days a week at the toll‐free telephone number on your Blue Cross and Blue Shield identification card. Please read the provisions below very carefully. Your Providers may call Blue Cross and Blue Shield for you, when required, but it is your responsibility to ensure Preauthorization requirements are satisfied.
The reductions in benefits are specified below in the FAILURE TO PREAU
THORIZE OR NOTIFY provision within this section of this Certificate.
The procedures for notifying Blue Cross and Blue Shield are specified below in the BEHAVIORAL HEALTH PROGRAM PROCEDURE provision within this section of this Certificate.
INPATIENT SERVICE PREAUTHORIZATION REVIEW S Emergency Mental Illness or Substance Use Disorder
Rehabilitation Treatment Inpatient Hospital Admission Review Emergency Mental Illness or Substance Use Disorder Rehabilitation Treatment Inpatient Hospital Admission review is not a guarantee of benefits. Actual availability of benefits is subject to eligibility and the other terms, conditions, limitations, and exclusions of this Certificate.
In order to receive maximum benefits under this Certificate, you or someone on your behalf must notify Blue Cross and Blue Shield no later than two business days or as soon as reasonably possible after the admission for the treatment of Mental Illness or Substance Use Disorder Rehabilitation Treatment has occurred. If the call is made any later than the specified time period, you will not be eligible for maximum benefits.
Providers may Preauthorize services for you, when required, but it is your responsibility to ensure Preauthorization requirements are satisfied.
S Non-Emergency Mental Illness or Substance Use Disorder Rehabilitation Treatment Preadmission Review
Non-Emergency Mental Illness or Substance Use Disorder Rehabilitation Treatment Preadmission Review is not a guarantee of benefits. Actual availability of benefits is subject to eligibility and the other terms, conditions, limitations, and exclusions of this Certificate.
In order to receive maximum benefits under this Certificate, you must Preauthorize admissions for Substance Use Disorder Rehabilitation Treatment, Residential Treatment Centers and Partial Hospitalization Treatment Programs by calling Blue Cross and Blue Shield. Providers may Preauthorize services for you, when required, but it is your responsibility to ensure Preauthorization requirements are satisfied. This call must be made at least one business day prior to admissions for Substance Use Disorder Rehabilitation Treatment, Residential Treatment Centers and Partial Hospitalization Treatment Programs. Blue Cross and Blue Shield will obtain information regarding the service(s) and may discuss proposed treatment with your Behavioral Health Practitioner.
S Length of Stay/Service Review
Length of stay/service review is not a guarantee of benefits. Actual availability of benefits is subject to eligibility and the other terms, conditions, limitations, and exclusions of this Certificate.
Upon completion of an Emergency Mental Illness or Substance Use Disorder Rehabilitation Treatment Inpatient Admission Review or a N o n - E m e rg e n c y M e n t a l I l l n e ss o r S u b st a n c e U se D i so r d e r Rehabilitation Treatment Preadmission Review, Blue Cross and Blue Shield will send you a letter confirming that you or your representative called Blue Cross and Blue Shield. A letter authorizing a length of service or length of stay will be sent to you, your Behavioral Health Practitioner and/or the Hospital or facility.
An extension of the length of stay/service will be based solely on whether continued Inpatient care or other health care service is Medically Necessary. In the event that the extension is determined not to be Medically Necessary, the coverage for the length of stay/service will not be extended.
OUTPATIENT SERVICE PREAUTHORIZATION REVIEW
Outpatient service Preauthorization review is not a guarantee of benefits.
Actual availability of benefits is subject to eligibility and the other terms, conditions, limitations, and exclusions of this Certificate.
In order to receive maximum benefits under this Certificate for the following Outpatient services for the treatment of Mental Illness or Substance Use Dis
order Rehabilitation Treatment, you must Preauthorize the following Outpatient service(s) by calling Blue Cross and Blue Shield:
S Applied behavioral analysis (ABA) services S Electroconvulsive therapy
S Intensive Outpatient Programs
S Repetitive Transcranial Magnetic Stimulation S Psychological or neuropsychological testing in some
cases. (Blue Cross and Blue Shield will notify your Provider if Preauthorization is required for these test
ing services.)
In‐Network and Out‐of‐Network Providers may Preauthorize services for you, when required, but it is your responsibility to ensure Preauthorization require
ments are satisfied. This call must be made at least one business day prior to receiving the planned Outpatient service. Blue Cross and Blue Shield will ob
tain information regarding the Outpatient service(s) and may discuss proposed treatment with your Behavioral Health Practitioner.
MEDICALLY NECESSARY DETERMINATION
The decision that a Mental Illness or Substance Use Disorder admission or an Outpatient service is not Medically Necessary, as such term is defined in this Certificate, will be based on generally accepted medical standards. If the Blue Cross and Blue Shield Physician concurs that the Mental Illness or Substance Use Disorder admission or Outpatient service does not meet the criteria for Medically Necessary care, some days, services or the entire hospitalization will be denied. Blue Cross and Blue Shield will send a letter to you, your Behavioral Health Practitioner and the Hospital or facility with a determination of your Preauthorization review no later than 15 calendar days after Blue Cross and Blue Shield receives the request for Preauthorization review. The letter will specify the dates and/or services that are not considered Medically Necessary. In some instances, these letters will not be received prior to your scheduled date of admission or service. For further details regarding Medically Necessary care and other exclusions from coverage under this Certificate, see the section entitled, “EXCLUSIONS—WHAT IS NOT COVERED."
Blue Cross and Blue Shield does not determine your course of treatment or whether you receive particular health care services. The decision regarding the course of treatment and receipt of particular health care services is a matter entirely between you and your Behavioral Health Practitioner. Blue Cross and Blue Shield's determination of Medically Necessary care is limited to merely whether a proposed admission, continued hospitalization, Outpatient service or other health care service is Medically Necessary under this Certificate.
Blue Cross and Blue Shield will make the initial decision whether an Inpatient admission, Outpatient service or other behavioral health care service is not Medically Necessary. In most instances, this decision is made by Blue Cross and Blue Shield after you have been hospitalized or have received other
behavioral health care services and after a claim for payment has been submitted.
Remember that your Blue Cross and Blue Shield Certificate does not cover the cost of hospitalization or any behavioral health care services that are not Medically Necessary. The fact that your Behavioral Health Practitioner or another health care Provider may prescribe, order, recommend or approve an Inpatient admission, Outpatient service or other behavioral health care service does not of itself make such admission or service Medically Necessary. Even if your Behavioral Health Practitioner prescribes, orders, recommends, approves, or views an admission or other behavioral health care services as Medically Necessary, Blue Cross and Blue Shield will not pay for the admission or services if the Blue Cross and Blue Shield Physician determines they were not Medically Necessary.
BEHAVIORAL HEALTH PROGRAM PROCEDURE
When you contact Blue Cross and Blue Shield, you should be prepared to provide the following information:
1. the name of the attending and/or admitting Behavioral Health Practitioner;
2. the name of the Hospital or facility where the admission and/or service has been scheduled, when applicable;
3. the scheduled admission and/or service date; and
4. a preliminary diagnosis or reason for the admission and/or service.
Once contacted, Blue Cross and Blue Shield:
1. will review the medical information provided and follow‐up with the Behavioral Health Practitioner;
2. may determine that the admission and/or services rendered or to be rendered are not Medically Necessary.
APPEAL PROCEDURE
If you or your Physician disagree with the determination of Blue Cross and Blue Shield prior to or while receiving services, that decision may be appealed by contacting Blue Cross and Blue Shield.
In some instances, the resolution of the appeal process will not be completed until your admission or service has occurred and/or your assigned length of stay/service has elapsed. If you disagree with a decision after Claim processing has taken place or upon receipt of the notification letter from Blue Cross and Blue Shield, you may appeal that decision by having your Behavioral Health Practitioner call the contact person indicated in the notification letter or by submitting a written request to:
Blue Cross and Blue Shield of Illinois Appeals Coordinator
Blue Cross and Blue Shield BH Program P. O. Box 660240
Dallas, TX 75266-0240 Fax Number: 1‐877‐361‐7656
You must exercise the right to this appeal as a precondition to taking any action against Blue Cross and Blue Shield, either at law or in equity.
Additional information about appeals procedures is set forth in the CLAIM APPEALS PROCEDURES provision of the HOW TO FILE A CLAIM section of this Certificate.
FAILURE TO PREAUTHORIZE OR NOTIFY
The final decision regarding your course of treatment is solely your responsibility and Blue Cross and Blue Shield will not interfere with your relationship with any Behavioral Health Practitioner. However, the Behavioral Health Program has been established for the specific purpose of assisting you in maximizing your benefits provided under this Certificate.
Should you fail to Preauthorize or notify Blue Cross and Blue Shield as required in the INPATIENT SERVICE PREAUTHORIZATION REVIEW provision within this section of this Certificate, you will then be responsible for the first $1,000 or 50%, whichever is less, of the Hospital or facility charges for an eligible Inpatient stay in addition to any deductibles, Copayments Coinsurance and/or out-of-pocket amounts that are your responsibility under this Certificate. This amount shall not be eligible for later consideration as an unreimbursed expense under any benefit section of this Certificate nor can it be applied to your out‐of‐pocket expense limit, if applicable to this Certificate.
There is no penalty for failure to notify Blue Cross and Blue Shield for Outpatient behavioral health services.
IMPORTANT: If you decide to receive health care that is not a Covered S e r v i c e , s u c h a s s e r v i c e s t h a t a r e d e t e r m i n e d t h r o u g h t h e Preauthorization review process not to be Medically Necessary, then no reimbursement is available under this Certificate and you are responsible to pay the full amount billed by the Provider you chose. For additional d e t a i l s , p l e a s e r e a d t h e a b o v e M E D I C A L LY N E C E S S A R Y DETERMINATION provision within this section of this Certificate.
CASE MANAGEMENT
In some cases, the case manager may offer an alternative treatment plan. If you and your Physician choose the alternative treatment plan, then alternative benefits may be provided as described in this Certificate.
Alternative benefits will be provided only so long as it has been determined that the alternative services are Medically Necessary and cost‐effective. The case manager will continue to be available for the duration of your condition.
The total maximum payment for alternative services shall not exceed the total benefits for which you would otherwise be entitled under this Certificate.
Provision of alternative benefits in one instance shall not result in an obligation to provide the same or similar benefits in any other instance. In
addition, the provision of alternative benefits shall not be construed as a waiver of any of the terms, conditions, limitations, and exclusions of this Certificate.
MEDICARE ELIGIBLE MEMBERS
The provisions of this section do not apply to you if you are Medicare eligible and have secondary coverage provided under this Certificate.