Behavioral Health Medical Necessity Criteria & Prior Authorization

Medical Necessity Criteria

Refer to Medical Necessity Criteria - Behavioral Health for information utilized by BCBSTX for its group, retail and government products.

Prior Authorization Requirements

The member’s plan may require prior authorization for certain Behavioral Health (BH) services. It’s critical to check eligibility and benefits first via the Availity® Essentials or your preferred web vendor, prior to rendering care and services. In addition to checking membership/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.

Services Requiring Prior Authorization

Inpatient and Alternative Levels of Care 

  • Prior authorization is required for all inpatient, residential treatment center (RTC) and partial hospitalization admissions.
  • 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 and to determine if RTC services are covered by a specific employer group, members or behavioral health professionals and physicians may call the Behavioral Health number that is listed on the back of the member’s ID card.

Outpatient Services

These intensive outpatient services require authorization prior to initiation of service to determine that the services are medically necessary, clinically appropriate and contribute to the successful outcome of treatment.

  • Intensive Outpatient Programs (IOP)
  • Applied Behavior Analysis (ABA)
  • Outpatient Electroconvulsive therapy (ECT)
  • Repetitive Transcranial Magnetic Stimulation (rTMS)
  • Psychological testing and neuropsychological testing in some cases; BCBSTX would notify the provider if prior authorization is required for these testing services.

This requirement applies only for members who have BH Outpatient Management as part of their BH benefit plan through BCBSTX.

Federal Employee Program® (FEP®) members are managed by BCBSTX. FEP members must request prior authorization for Applied Behavior Analysis (ABA), Electroconvulsive Therapy (ECT) and Repetitive Transcranial Magnetic Stimulation (rMTS) services but are not required to request prior authorization for Partial Hospitalization Programs (PHP) or any other outpatient behavioral health services.

Failure to prior authorize services could result in reduced or denied benefits or post service medical necessity reviews. For HMO plans, provider may not seek reimbursement from the member.

Prior Authorization Exemptions

Per Texas House Bill 3459, a provider may qualify for an exemption from submitting Behavioral Health prior authorization requests for particular health care service(s) for all fully insured and certain Administrative Services Only (ASO) groups. Refer to the Prior Authorization Exemption page for more information.  

Prior Authorization Process

Behavioral health providers need to obtain prior authorization for services which require it before rendering services. Members may also be responsible for requesting prior authorization based on their benefit plan. Behavioral health professionals, physicians or member's family member may request prior authorization on behalf of the member. BCBSTX will comply with all federal and state confidentiality regulations before releasing any information about the member. All services must be medically necessary.

Providers can request prior authorization online:

Outpatient Services:

  • Prior authorization for outpatient services requires completion of forms located under Education and Reference/Forms on the provider website.
  • Prior authorization requirements for ABA services are outlined on Management of ABA located in the Related Resources section under Clinical Resources/Behavioral Health on the provider website.

Automated submission of documents is available for some behavioral health services. Please consult the Claims & Eligibility/Electronic Commerce section of the Texas provider website: bcbstx.com/provider. 

For additional contact information, refer to Behavioral Health Contacts & Additional Information page.

 

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. BCBSIL makes no endorsement, representations or warranties regarding any products or services provided by third party vendors such as Availity.