Behavioral Health Medical Necessity Criteria and Prior Authorization
Our behavioral health team of licensed clinicians uses nationally recognized, evidence-based or state and federally mandated clinical review criteria for all behavioral health decisions.
Commercial members
Clinicians use the following guidelines to determine whether a requested level of care is medically necessary:
For addiction disorders, the American Society of Addiction Medicine’s The ASAM Criteria (addiction disorders), our medical policies, nationally recognized clinical practice guidelines and independent professional judgment
Benefit availability also depends on specific provisions under the member’s benefit plan. Call the number on the member’s ID card if you have questions.
Government program members
Clinicians use the following hierarchy of clinical criteria to determine the most appropriate level of care for our members:
Professional judgment and continuous improvement
The appropriate use of treatment guidelines requires professional medical judgment and may require adapting to local practice patterns. Professional medical judgment is required in all phases of health care delivery and management and should include consideration of members’ individual circumstances. The guidelines are not intended as a substitute for this important professional judgment.
We evaluate and approve all of the medical necessity guidelines listed above at least annually. Final approval by the behavioral health chief medical officer is required. The criteria are then presented annually to the Behavioral Health Quality Improvement Committee for review, recommendations and approval.
Prior authorization requirements
The member’s plan may require prior authorization for certain behavioral health services. It’s critical to check eligibility and benefits first via Availity Essentials or your preferred web vendor, prior to rendering care and services. In addition to checking membership and coverage status and other important details, this step returns information on prior authorization requirements and utilization management vendors, if applicable.
When Magellan or another vendor is responsible for managing the care, providers should contact the vendor for prior authorization.
Prior authorization is required for all inpatient, residential treatment center, partial hospitalization and some intensive services, which may include services such as applied behavior analysis, intensive outpatient program or transcranial magnetic stimulation.
Elective or non-emergency hospital admissions must be authorized prior to admission or within two business days of an emergency admission.
To determine eligibility and benefit coverage prior to service, members or behavioral health professionals and physicians may call the behavioral health number on the member’s ID card.
Request prior authorization online:
Prior Authorization for Federal Employee Program® members managed by BCBSTX
FEP® members must request prior authorization for applied behavior analysis, electroconvulsive therapy and transcranial magnetic stimulation services but are not required to request prior authorization for partial hospitalization programs or any other outpatient behavioral health services.
Failure to prior authorize for services could result in reduced or denied benefits or post-service medical necessity reviews. For HMO plans, providers may not seek reimbursement from the member.
Prior authorization exemptions
Per Texas House Bill 3459, you may qualify for an exemption from submitting behavioral health prior authorization requests for particular health care services for all fully insured and certain Administrative Services Only groups. Refer to our Prior Authorization Exemptions page for more information.
Prior authorization and recommended clinical review process
Behavioral health providers need to obtain prior authorization for services that require it before rendering services. Members may also be responsible for requesting prior authorization based on their benefit plan. Behavioral health professionals, physicians or a member’s family members may request prior authorization on behalf of the member. We will comply with all federal and state confidentiality regulations before releasing any information about the member. All services must be medically necessary.
All behavioral health benefits are subject to the terms and conditions as listed in the member’s benefit plan. The behavioral health program is available only to those members whose health plans include behavioral health benefits through BCBSTX. Some members may not have outpatient behavioral health management. All behavioral health benefits are subject to the terms and conditions as listed in the member’s benefit plan.
Checking eligibility and/or benefit information and/or obtaining prior authorization is not a guarantee of payment. Benefits will be determined once a claim is received and will be based upon, among other things, the member’s eligibility and the terms of the member’s certificate of coverage, including, but not limited to, exclusions and limitations applicable on the date services were rendered. If you have any questions, call the number on the member’s ID card.
Availity is a trademark of Availity, LLC, a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to BCBSTX. BCBSTX makes no endorsement, representations or warranties regarding third party vendors and the products and services they offer.
The American Society of Addiction Medicine is an independent company that has contracted with BCBSTX to provide utilization management support for members with coverage through BCBSTX. BCBSTX makes no endorsement, representations or warranties regarding third-party vendors and the products and services they offer.
HEDIS is a registered trademark of NCQA.
MCG Care Guidelines are administered and provided by MCG Health, an independent company that has contracted with BCBSTX to provide care and disease management for members with coverage through BCBSTX.
