Behavioral Health Needs Management. The Contractor must maintain a structured process for identifying and addressing complex behavioral health needs at all levels of care and in all residential settings. Qualified Behavioral Health Providers must proactively coordinate and follow Enrollee progress through the continuum of care.
Behavioral Health Needs Management. The Contractor must maintain a structured process for identifying and addressing complex behavioral health needs at all levels of care and in all residential settings. Qualified behavioral health Providers must proactively coordinate and follow Enrollee progress through the continuum of care. The Contractor shall implement all Current Procedural Terminology (CPT) evaluation and management codes for behavioral health services set forth in Appendix A as most recently adopted by the American Medical Association and CMS; and shall pay no less than the MassHealth rate for such CPT codes. Substance Use Disorder Services Prior authorization shall not be required for the following services: Inpatient Substance Use Disorder Services (Level IV), as defined in Appendix A, Exhibit 1; Acute Treatment Services (ATS) for Substance Use Disorders (Level III.7), as defined in Appendix A, Exhibit 1; Clinical Support Services (CSS), as defined in Appendix A, Exhibit 1, for Substance Use Disorders (Level III.5). The Contractor may implement utilization review procedures on the seventh day of a patient’s stay for CSS, but shall not make any utilization review decisions that impose any restriction or deny any future medically necessary CSS unless a patient has received at least 14 consecutive days of CSS; The following Outpatient Services: Counseling (including Couples/Family Treatment, Group Treatment, and Individual Treatment) and Ambulatory Detoxification, as defined in Appendix A, Exhibit 1; The following Non-24-Hour Diversionary Services: Structured Outpatient Addiction Program (SOAP), as defined in Appendix A, Exhibit 1; Intensive Outpatient Program (IOP), as defined in Appendix A, Exhibit 1; Partial Hospitalization as defined in Appendix A, Exhibit 1, with short-term day or evening mental health programming available seven days per week; and The initiation or re-initiation of a buprenorphine/naloxone prescription of 32 mg/day or less, for either brand formulations (e.g. Suboxone™, Zubsolv™, Bunavail™) or generic formulations, provided, however, that the Contractor may have a preferred formulation. Contractor may establish review protocols for continuing prescriptions. Notwithstanding the foregoing, the Contractor may implement prior authorization for buprenorphine (Subutex™) and limit coverage to pregnant or lactating women and individuals allergic to naloxone, provided such limitations are clinically appropriate. Providers providing Clinical Support Services for Substanc...
