Mental Health and Substance Use Disorder Benefits. Blue Shield’s Mental Health Service Administrator (MHSA) arranges and administers Mental Health and Substance Use Disorder Services for Blue Shield Members within California. All non-emer- gency inpatient Mental Health and Substance Use Disorder Services, including Residential Care, and Other Outpatient Mental Health and Substance Use Disorder Services must be prior authorized by the MHSA. Benefits are provided for professional office visits for the diagnosis and treatment of Mental Health and Substance Use Disorder Conditions in the indi- vidual, Family or group setting. Benefits are provided for Outpatient Facility and professional services for the diagnosis and treat- ment of Mental Health and Substance Use Disor- der Conditions. These services may also be provided in the office, home or other non-institutional setting. Other Outpatient Mental Health and Substance Use Disorder Services include, but may not be limited to the following:
Mental Health and Substance Use Disorder Benefits. Blue Shield’s Mental Health Service Administrator (MHSA) administers Mental Health and Substance Use Disorder services from MHSA Participating Providers for Members in California. Blue Shield administers Mental Health and Substance Use Disorder services
Mental Health and Substance Use Disorder Benefits. The coverage described below is designed to comply with requirements under the Xxxx Xxxxxxxxx-Xxxx Xxxxxxxx Mental Health Parity and Addiction Equity Act of 2008. Mental health services will be provided on an inpatient and outpatient basis and include mental health conditions. These conditions affect the individual’s ability to cope with the requirements of daily living. If you need mental health and/or substance use disorder treatment, you may choose any provider participating in our behavioral health network. You can search for network behavioral health providers by using the “Find a Provider” function at XxxxxxxxxxXxxxxxxx.xxx or by calling Member Services at 1-855-745-5507 (TTY 1-844- 517-3431). Deductible amounts, copayment or coinsurance amounts and treatment limits for covered mental health and substance use disorder benefits will be applied in the same manner as physical health service benefits. Covered services for mental health and substance use disorder are included on a non-discriminatory basis for all members for the diagnosis and medically necessary treatment of mental, emotional, or substance use disorders as defined in this policy. When making coverage determinations, our behavioral health and substance use disorder utilization management staff employ established level of care guidelines and medical necessity criteria that are based on currently accepted standards of practice and take into account legal and regulatory requirements. They utilize Change Healthcare’s InterQual criteria for mental health determinations and American Society of Addiction Medicine (ASAM) criteria for substance use disorder determinations. Services should always be provided in the least restrictive clinically appropriate setting. Any determination that requested services are not medically necessary will be made by a qualified licensed mental health professional. Covered Inpatient and Outpatient mental health and/or substance use disorder services are as follows:
Mental Health and Substance Use Disorder Benefits. Blue Shield’s Mental Health Service Administrator (MHSA) administers Mental Health Services and Substance Use Disorder Services from MHSA Participating Providers for Members in California. See the Out-of-area services section for an explanation of how Benefits are administered for out-of-state services. The MHSA Participating Provider must get prior authorization from the MHSA for all non- emergency Hospital admissions for Mental Health Services and Substance Use Disorder Services, and for certain outpatient Mental Health and Substance Use Disorder Services. See the Medical management section for more information about prior authorization. The MHSA Participating Providers network is separate from Blue Shield’s Participating Provider network. Visit xxxxxxxxxxxx.xxx and click on Find a Doctor to access the MHSA Participating Provider network. Benefits are available for professional office visits, including Physician office visits, for the diagnosis and treatment of Mental Health Conditions and Substance Use Disorder Conditions in an individual, Family, or group setting. Benefits are also available for telebehavioral health online counseling services, psychotherapy, and medication management with a mental health or substance use disorder provider.
Mental Health and Substance Use Disorder Benefits. Blue Shield’s Mental Health Service Administra- tor (MHSA) arranges and administers Mental Health Services and Substance Use Disorder Ser- vices for Blue Shield Members within California. See the Out-Of-Area Services, BlueCard Program section for an explanation of how payment is made for out of state services. All Non-Emergency inpatient Mental Health and Substance Use Disorder Services, including Resi- dential Care, and Other Outpatient Mental Health and Substance Use Disorder Services are subject to the Benefits Management Program and must be prior authorized by the MHSA. See the Benefits Management Program section for complete infor- mation Benefits are provided for professional (Physician) office visits for the diagnosis and treatment of Mental Health Conditions and Substance Use Dis- order Conditions in the individual, family or group setting Benefits are provided for Outpatient Facility and professional services for the diagnosis and treat- ment of Mental Health and Substance Use Disor- der Conditions. These services may also be pro- vided in the office, home or other non-institutional setting. Other Outpatient Mental Health and Sub- stance Use Disorder Services include, but may not be limited to, the following:
Mental Health and Substance Use Disorder Benefits. Cenpatico Behavioral Health, LLC (Cenpatico) oversees the delivery and oversight of covered behavioral health and substance use disorder services for Ambetter from Sunshine Health. If you need mental health and/or substance use disorder treatment, you may choose any provider participating in Cenpatico’s provider network and do not need a referral from your primary care physician in order to initiate treatment. Deductibles, copayment or coinsurance amounts and treatment limits for covered mental health and substance use disorder benefits will be applied in the same manner as physical health service benefits. Covered services for mental health and substance use disorder are included on a non‐discriminatory basis for all Members for the diagnosis and medically necessary and active treatment of mental, emotional, and/or substance use disorders as defined in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association. Diagnoses known as “V Codes” are eligible service expenses only when billed as a supporting diagnosis. When making coverage determinations, Cenpatico utilizes established level of care guidelines and medical necessity criteria that are based on currently accepted standards of practice and take into account legal and regulatory requirements. Cenpatico utilizes “Interqual” criteria for mental health determinations and “ASAM” criteria for substance abuse determinations. Services should always be provided in the least restrictive clinically appropriate setting. Any determination that requested services are not medically necessary will be made by a qualified licensed mental health professional. Covered Inpatient, Intermediate and Outpatient mental health and/or substance use disorder services are as follows: Inpatient
Mental Health and Substance Use Disorder Benefits. Parity Requirements
i) The Contractor shall comply with mental health and substance use disorder benefits parity requirements for aggregate lifetime and annual dollar limits specified in 42 CFR 438.905.
ii) The Contractor shall comply with mental health and substance use disorder benefits parity requirements for financial requirements and treatment limitations specified in 42 CFR 438.910.
Mental Health and Substance Use Disorder Benefits. Blue Shield’s Mental Health Service Administrator (MHSA) administers Mental Health Services and Substance Use Disorder Services from MHSA Participating Providers for Members in California. Blue Shield administers Mental Health Services and Substance Use Disorder Services from MHSA Non-Participating Providers for Members in California. See the Out-of-area services section for an explanation of how Benefits are administered for out-of-state services. The MHSA Participating Provider must get prior authorization from the MHSA for all non- emergency Hospital admissions for Mental Health Services and Substance Use Disorder Services, and for certain outpatient Mental Health and Substance Use Disorder Services. See the Medical Management Programs section for more information about prior authorization. The MHSA Participating Providers network is separate from Blue Shield’s Participating Provider network. Visit xxxxxxxxxxxx.xxx and click Find a Doctor to access the MHSA Participating Provider network. Benefits are available for professional office visits, including Physician office visits, for the diagnosis and treatment of Mental Health Conditions and Substance Use Disorder Conditions in an individual, Family, or group setting. Benefits are also available for telebehavioral health online counseling services, psychotherapy, and medication management with a mental health or substance use disorder provider.
Mental Health and Substance Use Disorder Benefits. Our behavioral health and substance use vendor oversees the delivery and oversight of covered behavioral health and substance use disorder services for Ambetter from Sunshine Health. If you need mental health or substance use disorder treatment, you may choose any provider participating in our behavioral health and substance use vendor’s provider network and do not need a referral from your primary care physician in order to initiate treatment. Deductible, amounts, copayment or coinsurance amounts and treatment limits for covered mental health and substance use disorder benefits will be applied in the same manner as physical health service benefits. Covered services for mental health and substance use disorder are included on a non‐discriminatory basis for all members for the diagnosis and medically necessary and active treatment of mental, emotional, or substance use disorders as defined in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association. When making coverage determinations, our behavioral and substance use vendor utilizes established level of care guidelines and medical necessity criteria that are based on currently accepted standards of practice and take into account legal and regulatory requirements: “Interqual” criteria for mental health determinations and “American Society of Addiction Medicine” criteria for substance abuse determinations. Services should always be provided in the least restrictive clinically appropriate setting. Any determination that requested services are not medically necessary will be made by a qualified licensed mental health professional. Covered inpatient and outpatient mental health or substance use disorder services are as follows: Inpatient
Mental Health and Substance Use Disorder Benefits. The coverage described below is intended to comply with requirements under the Xxxx Xxxxxxxxx-Xxxx Xxxxxxxx Mental Health Parity and Addiction Equity Act of 2008.
