Behavioral Health Services Care Coordination and Management Sample Clauses

Behavioral Health Services Care Coordination and Management. The Health Plan shall be responsible for the coordination and management of behavioral health services and continuity of care for all enrollees. At a minimum, the Health Plan shall provide the following services to its enrollees:
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Behavioral Health Services Care Coordination and Management. The Health Plan shall be responsible for the coordination and management of Behavioral Health Services and continuity of care for all Enrollees. At a minimum, the Health Plan shall provide the following services to its Enrollees: 1. Minimize disruption to the Enrollee as a result of any change in behavioral health care providers or behavioral health care case managers that occur as a result of this Contract. For new Enrollees who had been receiving Behavioral Health Services, the Health Plan shall continue to authorize all valid claims for services until the Health Plan has: a. Reviewed the Enrollee's treatment plan; b. Developed an appropriate written transition plan; and c. Implemented the written transition plan. 2. If the previous behavioral health care provider is unable to allow the Health Plan access to the Enrollee's Medical Records because the Enrollee refuses to release his/her records, then the Health Plan shall provide: .a Up to four (4) sessions of individual or group therapy; .b One (1) psychiatric medical session; .c Two (2) one-hour intensive therapeutic on-site; or .d Six (6) days of day treatment services.
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Behavioral Health Services Care Coordination and Management. The Health Plan shall be responsible for the coordination and management of behavioral health services and continuity of care. At a minimum, the Health Plan shall maintain written case coordination and documentation for all enrollees receiving care coordination services, and continuity of care protocols, that include the following: 1. Documentation of all emergency behavioral health services received by an enrollee, along with any follow-up services, in the enrollee's behavioral health medical records. The Health Plan shall also assure the PCP receives the information about the emergency behavioral health services for filing in the PCP's medical record. 2. Documentation of all referral services in the enrollees’ behavioral health clinical records. 3. Provision of appropriate referral of the enrollee for non-covered services to the appropriate service setting. The Health Plan shall request referral assistance, as needed, from the Medicaid Area Office. The Health Plan is encouraged to use the Florida Supplement to the American Society of Addictions Medicine Patient Placement Criteria for coordination and treatment of substance abuse related disorders with substance abuse providers. The Health Plan shall provide coordination of care with community-based substance abuse agencies as part of its policies and procedures developed for continuity of care for enrollees who are diagnosed with mental illness and substance abuse or dependency. 4. Coordination of care with community-based substance abuse agencies for enrollees who are diagnosed with mental illness and substance abuse or dependency. 5. Participation in the DCF planning process, where such exists (see s. 394.75, F.S.). 6. Sharing with other Health Plans and providers serving the enrollee the results of its identification and assessment of any enrollee with behavioral health and/or comorbidity issues. 7. Ensuring that enrollees who are being discharged from an inpatient facility have a follow-up appointment scheduled within seven (7) calendar days. 8. Coordination with inpatient facilities prior to the enrollee’s discharge to ensure that prescribed medications are listed on the Health Plan’s PDL or the provider has submitted the appropriate required documentation to complete the Health Plan’s authorization process for non-formulary drugs. 9. Coordination with outpatient facilities to ensure that prescribed medications issued are listed on the Health Plan’s PDL or the provider has submitted the appropriate ...
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Behavioral Health Services Care Coordination and Management. The Health Plan shall be responsible for the coordination and management of behavioral health services and continuity of care for all enrollees. At a minimum, the Health Plan shall provide the following services to its enrollees: 1. Document all emergency behavioral health services received by an enrollee, along with any follow-up services, in the enrollee’s behavioral health medical records. The Health Plan shall also assure the PCP receives the information about the emergency behavioral health services for filing in the PCP’s medical record. 2. Document all referral services in the enrollees’ behavioral health clinical records. AMERIGROUP Florida, Inc. d/b/a Medicaid Non-Reform and Reform AMERIGROUP Community Care HMO Contract
Sample 1
Behavioral Health Services Care Coordination and Management a. The Health Plan shall be responsible for the coordination and management of Behavioral Health Services and continuity of care for all Enrollees. At a minimum, the Health Plan shall provide the following services to its Enrollees: (1) Minimize disruption to the Enrollee as a result of any change in Behavioral Health Care Providers or Behavioral Health Care Case Managers that occur as a result of this Contract. For new Enrollees who had been receiving Behavioral Health Services, the Health Plan shall continue to authorize all valid claims for services until the Health Plan has: (a) Reviewed the Enrollee’s treatment plan; (b) Developed an appropriate written transition plan; and (c) Implemented the written transition plan. (2) If the previous Behavioral Health Care Provider is unable to allow the Health Plan access to the Enrollee’s Medical Records because the Enrollee refuses to release his/her records, then the Health Plan shall provide: (a) Up to four (4) sessions of individual or group therapy; (b) One (1) psychiatric medical session; (c) Two (2) one-hour intensive therapeutic on-site sessions; or (d) Six (6) days of day treatment services. (3) Document all Emergency Behavioral Health Services received by an Enrollee, along with any follow-up services, in the Enrollee’s behavioral health Medical Records. The Health Plan shall also assure the PCP receives the information about the Emergency Behavioral Health Services for filing in the PCP’s Medical Record. (4) Document all referral services in the Enrollees’ behavioral health Medical Records. (5) Monitor Enrollees admitted to State mental health institutions by participating in discharge planning and community placement of Enrollees who are discharged within sixty (60) days of losing their Health Plan enrollment due to State institutionalization. The Agency shall sanction the Health Plan, as described in Section XIV, Sanctions, for any inappropriate over-utilization of State mental hospital services for its Enrollees. (6) Coordinate Hospital and institutional discharge planning for psychiatric admissions and substance abuse detoxification to ensure inclusion of appropriate post-discharge care. (a) Enrollees admitted to an acute care facility (inpatient Hospital or CSU) shall receive appropriate services upon discharge from the acute care facility. (b) The Health Plan shall have follow-up services available to Enrollees within twenty-four (24) hours of discharge from an acute care facility, provided the ...
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Related to Behavioral Health Services Care Coordination and Management

  • Clinical Management for Behavioral Health Services (CMBHS) System 1. request access to CMBHS via the CMBHS Helpline at (000) 000-0000. 2. use the CMBHS time frames specified by System Agency. 3. use System Agency-specified functionality of the CMBHS in its entirety. 4. submit all bills and reports to System Agency through the CMBHS, unless otherwise instructed.

  • Behavioral Health Services Behavioral health services include the evaluation, management, and treatment for a mental health or substance use disorder condition. For the purpose of this plan, substance use disorder does not include addiction to or abuse of tobacco and/or caffeine. Mental health or substance use disorders are those that are listed in the most updated volume of either: • the Diagnostic and Statistical Manual of Mental Disorders (DSM) published by the American Psychiatric Association; or • the International Classification of Disease Manual (ICD) published by the World Health Organization. This plan provides parity in benefits for behavioral healthcare services. Please see Section 10 for additional information regarding behavioral healthcare parity. This plan covers behavioral health services if you are inpatient at a general or specialty hospital. See Inpatient Services in Section 3 for additional information. This plan covers services at behavioral health residential treatment facilities, which provide: • clinical treatment; • medication evaluation management; and • 24-hour on site availability of health professional staff, as required by licensing regulations. This plan covers intermediate care services, which are facility-based programs that are: • more intensive than traditional outpatient services; • less intensive than 24-hour inpatient hospital or residential treatment facility services; and • used as a step down from a higher level of care; or • used a step-up from standard care level of care. Intermediate care services include the following: • Partial Hospital Program (PHP) – PHPs are structured and medically supervised day, evening, or nighttime treatment programs providing individualized treatment plans. A PHP typically runs for five hours a day, five days per week. • Intensive Outpatient Program (IOP) – An IOP provides substantial clinical support for patients who are either in transition from a higher level of care or at risk for admission to a higher level of care. An IOP typically runs for three hours per day, three days per week.

  • Outpatient Services Physicians, Urgent Care Centers and other Outpatient Providers located outside the BlueCard® service area will typically require You to pay in full at the time of service. You must submit a Claim to obtain reimbursement for Covered Services.

  • Pharmacy Services The Contractor shall establish a network of pharmacies. The Contractor or its PBM must provide at least two (2) pharmacy providers within thirty (30) miles or thirty (30) minutes from a member’s residence in each county, as well as at least two (2) durable medical equipment providers in each county or contiguous county.

  • COVERED HEALTHCARE SERVICES This section describes covered healthcare services. This plan covers services only if they meet all of the following requirements: • Listed as a covered healthcare service in this section. The fact that a provider has prescribed or recommended a service, or that it is the only available treatment for an illness or injury does not mean it is a covered healthcare service under this plan. • Medically necessary, consistent with our medical policies and related guidelines at the time the services are provided. • Not listed in Exclusions Section. • Received while a member is enrolled in the plan. • Consistent with applicable state or federal law. We review medical necessity in accordance with our medical policies and related guidelines. Our medical policies can be found on our website. Our medical policies are written to help administer benefits for the purpose of claims payment. They are made available to you for informational purposes and are subject to change. Medical policies are not meant to be used as a guide for your medical treatment. Your medical treatment remains a decision made by you with your physician. If you have questions about our medical policies, please call Customer Service. When a new service or drug becomes available, when possible, we will review it within six (6) months of one of the events described below to determine whether the new service or drug will be covered: • the assignment of an American Medical Association (AMA) Current Procedural Terminology (CPT) code in the annual CPT publication; • final Food and Drug Administration (FDA) approval; • the assignment of processing codes other than CPT codes or approval by governing or regulatory bodies other than the FDA; • submission to us of a claim meeting the criteria above; and • generally, the first date an FDA approved prescription drug is available in pharmacies (for prescription drug coverage only). During the review period, new services and drugs are not covered. For all covered healthcare services, please see the Summary of Medical Benefits and the Summary of Pharmacy Benefits to determine the amount that you pay and any benefit limits.

  • Behavioral Health Services – Mental Health and Substance Use Disorder Inpatient - Unlimited days at a general hospital or a specialty hospital including detoxification or residential/rehabilitation per plan year. Preauthorization may be required for services received from a non-network provider. 0% - After deductible 40% - After deductible Outpatient or intermediate careservices* - See Covered Healthcare Services: Behavioral Health Section for details about partial hospital program, intensive outpatient program, adult intensive services, and child and family intensive treatment. Preauthorization may be required for services received from a non-network provider. 0% - After deductible 40% - After deductible Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing 0% - After deductible 40% - After deductible Medication-assisted treatment - whenrenderedby a mental health or substance use disorder provider. 0% - After deductible 40% - After deductible Methadone maintenance treatment - one copayment per seven-day period of treatment. 0% - After deductible 40% - After deductible Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per coveredepisode. 0% - After deductible 40% - After deductible In a physician's office - limited to 12 visits per plan year. 0% - After deductible 40% - After deductible Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% - After deductible 40% - After deductible Services connected to dental care when performed in an outpatient facility * 0% - After deductible 40% - After deductible Inpatient/outpatient/in your home 0% - After deductible 40% - After deductible (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient diabetic supplies/equipment purchasedat licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 20% - After deductible 40% - After deductible Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible 40% - After deductible Enteral formula or food taken orally * 20% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 20% - After deductible The level of coverage is the same as network provider. Coverage provided for members from birth to 36 months. The provider must be certified as an EIS provider by the Rhode Island Department of Human Services. 0% - After deductible The level of coverage is the same as network provider. Asthma management 0% - After deductible 40% - After deductible Hospital emergency room 0% - After deductible The level of coverage is the same as network provider.

  • Inpatient Services Hospital Rehabilitation Facility

  • Cooperation and Coordination The Parties acknowledge and agree that it is their mutual objective and intent to minimize, to the extent feasible and legal, taxes payable with respect to their collaborative efforts under this Agreement and that they shall use all commercially reasonable efforts to cooperate and coordinate with each other to achieve such objective.

  • Program Management 1.1.01 Implement and operate an Immunization Program as a Responsible Entity 1.1.02 Identify at least one individual to act as the program contact in the following areas: 1. Immunization Program Manager;

  • Project Management and Coordination The Engineer shall coordinate all subconsultant activity to include quality of and consistency of work and administration of the invoices and monthly progress reports. The Engineer shall coordinate with necessary local entities.

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