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Karen Geiger
Associate General Counsel, Anthem Blue Cross and
Blue Shield of Wisconsin
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2014 Provider Expo
Anthem Blue Cross and Blue Shield is the trade name of Blue Cross Blue Shield of Wisconsin ("BCBSWi") which underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation ("Compcare") which underwrites or administers the HMO policies; and Compcare and BCBSWi collectively which underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.
This presentation contains proprietary information of Anthem Blue Cross and Blue Shield. It is intended for Anthem providers. Any redistribution or other use is strictly forbidden.
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Anthem BlueCross and BlueShield 2014 Provider Expo
Agenda
Purpose
Benefit Impact 2014
Administrative Impact
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Anthem BlueCross and BlueShield 2014 Provider Expo
Purpose
Prevent health plans from imposing less favorable
benefit limitations on behavioral health benefits than
on medical benefits
Impacts
2010 – large group health plans
January 1, 2014 – ACA compliant plans
Renewals on or after July 1, 2014 – most individual and
small group plans
Not impacted
Transitional individual and small group policies
Retiree only plans
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Anthem BlueCross and BlueShield 2014 Provider Expo
Benefit Impacts 2014
Cost-sharing changes
Residential treatment centers
Methadone treatment
Nutritional counseling for eating disorders
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Anthem BlueCross and BlueShield 2014 Provider Expo
Administrative Impact
Non-quantitative treatment limitations –
administrative processes that could limit access
Provider network
Utilization management
Drug formulary
Provider payment
We must apply the same processes and procedures in
developing/applying these limitations as we do for
medical.
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Anthem BlueCross and BlueShield 2014 Provider Expo
Questions?
Anthem Blue Cross and Blue Shield is the trade name of Blue Cross Blue Shield of Wisconsin ("BCBSWi") which underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation ("Compcare") which underwrites or administers the HMO policies; and Compcare and BCBSWi collectively which underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.
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Christine Baldas, Manager Behavioral Health Services and
Melissa Walker, Network Support Consultant
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2014 Provider Expo
Anthem Blue Cross and Blue Shield is the trade name of Blue Cross Blue Shield of Wisconsin ("BCBSWi") which underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation ("Compcare") which underwrites or administers the HMO policies; and Compcare and BCBSWi collectively which underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.
This presentation contains proprietary information of Anthem Blue Cross and Blue Shield. It is intended for Anthem providers. Any redistribution or other use is strictly forbidden.
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Anthem BlueCross and BlueShield 2014 Provider Expo
Agenda
What this means for our members
What this means for providers
Levels of care that require authorization
How to obtain authorization
Residential Psychiatric Care – Symptoms & Behaviors
Residential Substance Abuse Care – Symptoms & Behaviors
Residential Eating Disorder Care – Symptoms & Behaviors
Other considerations
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Anthem BlueCross and BlueShield 2014 Provider Expo
What this means for our members
Expansion of benefits to include Residential Treatment
Centers
Coverage for Methadone
Coverage for nutritional counseling for Eating
Disorders
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Anthem BlueCross and BlueShield 2014 Provider Expo
What this means for providers
Ability to obtain Residential Treatment Center (RTC)
services for members
Ability to obtain reimbursement for Methadone
services
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Anthem BlueCross and BlueShield 2014 Provider Expo
Levels of care requiring precertification
Authorization is based on medical necessity
Inpatient:
Always
Residential Care:
Sometimes – Call to confirm
Partial Hospitalization (PHP):
Sometimes – Call to confirm
Intensive Outpatient (IOP):
Sometimes – Call to confirm
Applied Behavioral Analysis:
Not currently
Outpatient Office Visits:
No precert required
Methadone Maintenance:
No precert required
Other procedures or types of treatment:
Call to confirm
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Anthem BlueCross and BlueShield 2014 Provider Expo
How to obtain authorization
Call the number of the back of the member’s identification
card
Call the precertification number listed on the Wisconsin
Ready Reference Guide and select Behavioral Health
To verify status of an authorization, use the Interactive Care
Reviewer located under Auths and Referrals on Availity
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Anthem BlueCross and BlueShield 2014 Provider Expo
Residential Psychiatric Care
Symptoms & Behaviors
Behaviors consistent with clinical guidelines
Typically child/adolescent under 18 years
High risk or self injurious behavior that is a deterioration
from the member’s usual status
Member’s social environment includes temporary stressors or
limitations that would undermine treatment with the
expectation the situation will improve while member is in a
residential treatment center
A reasonable expectation that the illness or condition or level
of functioning will stabilize and improve , and that the
member will be able to return to outpatient treatment
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Anthem BlueCross and BlueShield 2014 Provider Expo
Residential Substance Abuse Care
Symptoms & Behaviors
Behaviors consistent with clinical guidelines
Member’s condition meets the diagnostic criteria for a
DSM Axis I or ICD-9 Substance Abuse and/or Dependence
diagnosis
Acute psychiatric symptoms that would interfere with
maintaining abstinence
Acute medical symptoms that would interfere with
maintaining abstinence
Evidence of major functional impairment in 2 domains
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Anthem BlueCross and BlueShield 2014 Provider Expo
Residential Eating Disorder Care
Symptoms & Behaviors
Behaviors consistent with clinical guidelines
For weight restoration BMI between 15-18 or weight between
75%-85% of ideal range and no medical instability
Other symptoms are controlled and eating disorder is the focus of
treatment
Continued restricting and purging is leading to weight loss which
will lead to medical instability and inpatient admission
Significant functional disruption from baseline in 2 domains
There is reasonable expectation that the member will benefit from
placement in a residential treatment center
Environment and support have significant deficits or conflicts that
would undermine the goals of treatment such that lower level of
care is unlikely to be successful
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Anthem BlueCross and BlueShield 2014 Provider Expo
Other Considerations
Networks vary depending on member’s plan
Verify facility is in-network status for a member’s plan
Use Anthem’s online provider directory
Call provider service
Authorization Requirements
View on “Precertification Guidelines” page on the WI public
provider website
Behavioral Health Clinical UM Guidelines
View on the “Behavioral Health Provider Resources” page on the
WI public provider website
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Anthem BlueCross and BlueShield 2014 Provider Expo
Questions?
Anthem Blue Cross and Blue Shield is the trade name of Blue Cross Blue Shield of Wisconsin ("BCBSWi") which underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation ("Compcare") which underwrites or administers the HMO policies; and Compcare and BCBSWi collectively which underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.
