Inpatient Mental Health and Substance Abuse Services. SAMPLE Benefits are provided when the Member is admitted under the care of a Contracting Physician as an inpatient in a hospital or other CareFirst BlueChoice-approved health care facility for treatment of Mental Illness, Emotional Disorders, and Substance Abuse as follows:
A. Hospital benefits will be provided, as described in Section 5, Inpatient Hospital Services, of this Description of Covered Services, on the same basis as a medical (non-Mental Health or Substance Abuse) admission.
B. Contracting Provider services provided to a hospitalized Member, including physician visits, charges for intensive care, or consultative services, only if CareFirst BlueChoice determines that the Contracting Provider rendered services to the Member and that such services were medically required to diagnose or treat the Member’s condition. The following benefits apply if the Member is an inpatient in a hospital covered under inpatient hospitalization benefits following CareFirst BlueChoice certification of the need and continued appropriateness of such services in accordance with CareFirst BlueChoice utilization management requirements:
1. Contracting Provider visits during the Member’s hospital stay;
2. Intensive care that requires a Contracting Provider’s attendance;
3. Consultation by another Contracting Provider when additional skilled care is required because of the complexity of the Member’s condition; and
C. Benefits are available for diagnosis and treatment for Substance Abuse, including inpatient detoxification and rehabilitation services in an acute care hospital or Qualified Treatment Facility. Members must meet the applicable criteria for acceptance into, and continued participation in, treatment facilities/programs, as determined by CareFirst BlueChoice.
Inpatient Mental Health and Substance Abuse Services. Covered services include the following:
A. Services for care and treatment of mental illness, emotional disorders, alcohol abuse or drug abuse, which, in the judgment of CareFirst BlueChoice, are Medically Necessary and treatable through inpatient hospitalization. Inpatient care is not covered if, in CareFirst BlueChoice's judgment, the condition and/or the treatment to be provided does not meet the criteria established by CareFirst BlueChoice for admission to a hospital. Hospitalization in a specialized facility that is not a CareFirst BlueChoice approved facility is not covered.
B. Diagnosis and treatment for the abuse of or addiction to alcohol and drugs, including inpatient detoxification and rehabilitative services in an acute care hospital or Qualified Substance Abuse Treatment Facility. A Member must meet the applicable criteria for acceptance into, and continued participation in, treatment facilities/programs, as determined by CareFirst BlueChoice.
C. Visits to the patient in the hospital or facility by Contracting Physicians or Contracting Providers are not to exceed one visit per day for each day that inpatient mental health and/or substance abuse benefits are being provided under the preceding paragraphs. For purposes of determining the number of covered inpatient professional visits utilized and the Copayments applicable to such services, a visit as used in Section 6 means an inpatient consultation or group or individual session that does not exceed one hour.
D. Other covered medical and medical ancillary services will be covered for conditions related to mental illness, emotional disorders, alcohol abuse and drug abuse on the same basis as other covered medical conditions.
Inpatient Mental Health and Substance Abuse Services. Benefits are provided when the Member is admitted as an inpatient in a hospital or other CareFirst- approved health care facility for treatment of Mental Illness, Emotional Disorders, and Substance Abuse as follows:
A. Hospital benefits will be provided, as described in Section 5, Inpatient Hospital Services, of this Description of Covered Services, on the same basis as a medical (non-Mental Health or Substance Abuse) admission.
B. Services provided to a hospitalized Member, including physician visits, charges for intensive care, or consultative services, only if CareFirst determines that the health care provider rendered services to the Member and that such services were medically required to diagnose or treat the Member’s condition. The following benefits apply if the Member is an inpatient in a hospital covered under inpatient hospitalization benefits following CareFirst certification of the need and continued appropriateness of such services in accordance with CareFirst utilization management requirements:
1. Health care provider visits during the Member’s hospital stay;
2. Intensive care that requires a health care provider’s attendance;
3. Consultation by another health care provider when additional skilled care is required because of the complexity of the Member’s condition; and
C. Benefits are available for diagnosis and treatment for Substance Abuse, including inpatient detoxification and rehabilitation services in an acute care hospital or Qualified Treatment Facility. Members must meet the applicable criteria for acceptance into, and continued participation in, treatment facilities/programs, as determined by CareFirst.
