Common use of Mental Health Services and Severe Mental Illness Services Clause in Contracts

Mental Health Services and Severe Mental Illness Services. All benefits are subject to the Utilization Management process through Behavioral Healthcare Options (BHO). Services must be offered in a treatment setting that is appropriate for the Medically Necessary level of care, as determined by staffing, ability to provide patient safety, treatment intensity, the diagnostic and therapeutic modalities available, the extent of supportive services and access to general medical care. Inpatient: A structured hospital-based program which provides twenty-four (24) hours a day, seven (7) days a week nursing care, medical monitoring, and physician availability; assessment and diagnostic services, daily physician visits, active behavioral health treatment, and specialty medical consultation with an immediacy needed to avoid serious jeopardy to the health of the Insured or others. Partial Hospitalization Programs (PHP): A structured program that maintains hours of service for at least twenty (20) hours per week during which assessment and diagnostic services, and active behavioral health treatment are provided. Intensive Outpatient Programs (IOP): A structured program that maintains hours of service for at least nine (9) hours per week for adults and six (6) hours per week for children or adolescents during which assessment and diagnostic services, and active behavioral health treatment are provided. Outpatient: Assessment, diagnosis and active behavioral health treatment that are provided in an ambulatory setting, including individual and group counseling services. Residential Treatment Center Services (RTC): A hospital-based program which provides twenty-four (24) hours a day, seven (7) days a week nursing care, medical monitoring, and physician availability; assessment and diagnostic services, daily physician visits and active behavioral health treatment services for the purpose of initiating the process of assisting an Insured with gaining the knowledge and skills needed to prevent recurrence of a mental health-related disorder. No benefits are available for psychosocial rehabilitation or care received as a custodial Inpatient. All non-routine, outpatient Mental Health or Severe Mental Illness Services require Prior Authorization. Insureds must call BHO at (000) 000-0000 or 0-000-000-0000 for assistance in scheduling their first appointment in order to verify that any requested Mental Health or Severe Mental Illness Services are Covered Services under the Plan, and that such Covered Services will be obtained at the appropriate level of care in order to be eligible for full benefit payment. A BHO coordinator will either assist in scheduling the appointment or will make a referral to the appropriate Plan Provider based on the service requested and the associated level of acuity. All inpatient Mental Health or Severe Mental Illness Services require Plan notification. Network facilities must provide notification of all inpatient admissions to the Plan. When these services are provided out of network, the Insured is responsible for providing the notification and relevant information to the Plan. Insureds should provide notice of emergent admissions within twenty-four (24) hours of admission or as soon as reasonably possible given the circumstances. The Insured may delegate their responsibility to provide notification to the non-network facility but it is the Insured’s responsibility to ensure that the Plan receives notification. Initial notification results in a medical necessity review based on plan requirements and may result in an adverse benefit determination. All admissions for Emergency Services are reviewed Retrospectively to determine if the treatment received was Medically Necessary and appropriate. If the Insured receives services other than Emergency Services in a Mental Health or Severe Mental Illness facility without obtaining Prior Authorization from SHL, benefits will be reduced to 50% of what the Insured would have received if the services had been Prior Authorized, provided however, that the benefits paid will not be less than 50% of the Eligible Medical Expenses. If the treatment received is not a Covered Service or if treatment is received for a condition which is not Medically Necessary, no benefit is payable.

Mental Health Services and Severe Mental Illness Services. All benefits are subject to the Utilization Management process through Behavioral Healthcare Options (BHO). Services must be offered in a treatment setting that is appropriate for the Medically Necessary level of care, as determined by staffing, ability to provide patient safety, treatment intensity, the diagnostic and therapeutic modalities available, the extent of supportive services and access to general medical care. Inpatient: A structured hospital-based program which provides twenty-four (24) hours a day, seven (7) days a week nursing care, medical monitoring, and physician availability; assessment and diagnostic services, daily physician visits, active behavioral health treatment, and specialty medical consultation with an immediacy needed to avoid serious jeopardy to the health of the Insured or others. Partial Hospitalization Programs (PHP): A structured program that maintains hours of service for at least twenty (20) hours per week during which assessment and diagnostic services, and active behavioral health treatment are provided. Intensive Outpatient Programs (IOP): A structured program that maintains hours of service for at least nine (9) hours per week for adults and six (6) hours per week for children or adolescents during which assessment and diagnostic services, and active behavioral health treatment are provided. Outpatient: Assessment, diagnosis and active behavioral health treatment that are provided in an ambulatory setting, including individual and group counseling services. Residential Treatment Center Services (RTC): A hospital-based program which provides twenty-four (24) hours a day, seven (7) days a week nursing care, medical monitoring, and physician availability; assessment and diagnostic services, daily physician visits and active behavioral health treatment services for the purpose of initiating the process of assisting an Insured with gaining the knowledge and skills needed to prevent recurrence of a mental health-related disorder. No benefits are available for psychosocial rehabilitation or care received as a custodial Inpatient. All non-routine, outpatient Mental Health or Severe Mental Illness Services require Prior Authorization. Insureds must call BHO at (000) 000-0000 or 0-000-000-0000 for assistance in scheduling their first appointment in order to verify that any requested Mental Health or Severe Mental Illness Services are Covered Services under the Plan, and that such Covered Services will be obtained at the appropriate level of care in order to be eligible for full benefit payment. A BHO coordinator will either assist in scheduling the appointment or will make a referral to the appropriate Plan Provider based on the service requested and the associated level of acuity. All inpatient Mental Health or Severe Mental Illness Services require Plan notification. Network facilities must provide notification of all inpatient admissions to the Plan. When these services are provided out of network, the Insured is responsible for providing the notification and relevant information to the Plan. Insureds should provide notice of emergent admissions within twenty-four (24) hours of admission or as soon as reasonably possible given the circumstances. The Insured Insureds may delegate their responsibility to provide Certificate of Coverage notification to the non-network facility but it is the Insured’s responsibility to ensure that the Plan receives notification. Initial notification results in a medical necessity review based on plan requirements and may result in an adverse benefit determination. All admissions for Emergency Services are reviewed Retrospectively to determine if the treatment received was Medically Necessary and appropriate. If the Insured receives services other than Emergency Services in a Mental Health or Severe Mental Illness facility without obtaining Prior Authorization from SHL, benefits will be reduced to 50% of what the Insured would have received if the services had been Prior Authorized, provided however, that the benefits paid will not be less than 50% of the Eligible Medical Expenses. If the treatment received is not a Covered Service or if treatment is received for a condition which is not Medically Necessary, no benefit is payable.

Mental Health Services and Severe Mental Illness Services. All benefits are subject to the Utilization Management process through Behavioral Healthcare Options (BHO). Services must be offered in a treatment setting that is appropriate for the Medically Necessary level of care, as determined by staffing, ability to provide patient safety, treatment intensity, the diagnostic and therapeutic modalities available, the extent of supportive services and access to general medical care. Inpatient: A structured hospital-based program which provides twenty-four (24) hours a day, seven (7) days a week nursing care, medical monitoring, and physician availability; assessment and diagnostic services, daily physician visits, active behavioral health treatment, and specialty medical consultation with an immediacy needed to avoid serious jeopardy to the health of the Insured or others. Partial Hospitalization Programs (PHP): A structured program that maintains hours of service for at least twenty (20) hours per week during which assessment and diagnostic services, and active behavioral health treatment are provided. Intensive Outpatient Programs (IOP): A structured program that maintains hours of service for at least nine (9) hours per week for adults and six (6) hours per week for children or adolescents during which assessment and diagnostic services, and active behavioral health treatment are provided. Outpatient: Assessment, diagnosis and active behavioral health treatment that are provided in an ambulatory setting, including individual and group counseling services. No benefits are available for psychosocial rehabilitation or care received as a custodial Inpatient. Residential Treatment Center Services (RTC): A hospital-based program which provides twenty-four (24) hours a day, seven (7) days a week nursing care, medical monitoring, and physician availability; assessment and diagnostic services, daily physician visits Certificate of Coverage and active behavioral health treatment services for the purpose of initiating the process of assisting an Insured with gaining the knowledge and skills needed to prevent recurrence of a mental health-related disorder. No benefits are available for psychosocial rehabilitation or care received as a custodial Inpatient. All non-routine, outpatient Mental Health or Severe Mental Illness Services require Prior Authorization. Insureds must call BHO at (000) 000-0000 or 0-000-000-0000 for assistance in scheduling their first appointment in order to verify that any requested Mental Health or Severe Mental Illness Services are Covered Services under the Plan, and that such Covered Services will be obtained at the appropriate level of care in order to be eligible for full benefit payment. A BHO coordinator will either assist in scheduling the appointment or will make a referral to the appropriate Plan Provider based on the service requested and the associated level of acuity. All inpatient Mental Health or Severe Mental Illness Services require Plan notification. Network facilities must provide notification of all inpatient admissions to the Plan. When these services are provided out of network, the Insured is responsible for providing the notification and relevant information to the Plan. Insureds should provide notice of emergent admissions within twenty-four (24) hours of admission or as soon as reasonably possible given the circumstances. The Insured may delegate their responsibility to provide notification to the non-network facility but it is the Insured’s responsibility to ensure that the Plan receives notification. Initial notification results in a medical necessity review based on plan requirements and may result in an adverse benefit determination. All admissions for Emergency Services are reviewed Retrospectively to determine if the treatment received was Medically Necessary and appropriate. If the Insured receives services other than Emergency Services in a Mental Health or Severe Mental Illness facility without obtaining Prior Authorization from SHL, benefits will be reduced to 50% of what the Insured would have received if the services had been Prior Authorized, provided however, that the benefits paid will not be less than 50% of the Eligible Medical Expenses. If the treatment received is not a Covered Service or if treatment is received for a condition which is not Medically Necessary, no benefit is payable.

Mental Health Services and Severe Mental Illness Services. All benefits are subject to the Utilization Management process through Behavioral Healthcare Options (BHO). Services must be offered in a treatment setting that is appropriate for the Medically Necessary level of care, as determined by staffing, ability to provide patient safety, treatment intensity, the diagnostic and therapeutic modalities available, the extent of supportive services and access to general medical care. Inpatient: A structured hospital-based program which provides twenty-four (24) hours a day, seven (7) days a week nursing care, medical monitoring, and physician availability; assessment and diagnostic services, daily physician visits, active behavioral health treatment, and specialty medical consultation with an immediacy needed to avoid serious jeopardy to the health of the Insured or others. Agreement of Coverage Partial Hospitalization Programs (PHP): A structured program that maintains hours of service for at least twenty (20) hours per week during which assessment and diagnostic services, and active behavioral health treatment are provided. Intensive Outpatient Programs (IOP): A structured program that maintains hours of service for at least nine (9) hours per week for adults and six (6) hours per week for children or adolescents during which assessment and diagnostic services, and active behavioral health treatment are provided. Outpatient: Assessment, diagnosis and active behavioral health treatment that are provided in an ambulatory setting, including individual and group counseling services. Residential Treatment Center Services (RTC): A hospital-based program which provides twenty-four (24) hours a day, seven (7) days a week nursing care, medical monitoring, and physician availability; assessment and diagnostic services, daily physician visits and active behavioral health treatment services for the purpose of initiating the process of assisting an Insured with gaining the knowledge and skills needed to prevent recurrence of a mental health-related disorder. No benefits are available for psychosocial rehabilitation or care received as a custodial Inpatient. All non-routine, outpatient Mental Health or Severe Mental Illness Services require Prior Authorization. Insureds must call BHO at (000) 000-0000 or 0-000-000-0000 for assistance in scheduling their first appointment in order to verify that any requested Mental Health or Severe Mental Illness Services are Covered Services under the Plan, and that such Covered Services will be obtained at the appropriate level of care in order to be eligible for full benefit payment. A BHO coordinator will either assist in scheduling the appointment or will make a referral to the appropriate Plan Provider based on the service requested and the associated level of acuity. All inpatient Mental Health or Severe Mental Illness Services require Plan notification. Network facilities must provide notification of all inpatient admissions to the Plan. When these services are provided out of network, the Insured is responsible for providing the notification and relevant information to the Plan. Insureds should provide notice of emergent admissions within twenty-four (24) hours of admission or as soon as reasonably possible given the circumstances. The Insured may delegate their responsibility to provide notification to the non-network facility but it is the Insured’s responsibility to ensure that the Plan receives notification. Initial notification results in a medical necessity review based on plan requirements and may result in an adverse benefit determination. All admissions for Emergency Services are reviewed Retrospectively to determine if the treatment received was Medically Necessary and appropriate. If the Insured receives services other than Emergency Services in a Mental Health or Severe Mental Illness facility without obtaining Prior Authorization from SHL, benefits will be reduced to 50% of what the Insured would have received if the services had been Prior Authorized, provided however, that the benefits paid will not be less than 50% of the Eligible Medical Expenses. If the treatment received is not a Covered Service or if treatment is received for a condition which is not Medically Necessary, no benefit is payable.

Mental Health Services and Severe Mental Illness Services. All benefits are subject to the Utilization Management process through Behavioral Healthcare Options (BHO). Services must be offered in a treatment setting that is appropriate for the Medically Necessary level of care, as determined by staffing, ability to provide patient safety, treatment intensity, the diagnostic and therapeutic modalities available, the extent of supportive services and access to general medical care. Inpatient: A structured hospital-based program which provides twenty-four (24) hours a day, seven (7) days a week nursing care, medical monitoring, and physician availability; assessment and diagnostic services, daily physician visits, active behavioral health treatment, and specialty medical consultation with an immediacy needed to avoid serious jeopardy to the health of the Insured Member or others. Partial Hospitalization Programs (PHP): A structured program that maintains hours of service for at least twenty (20) hours per week during which assessment and diagnostic services, and active behavioral health treatment are provided. Intensive Outpatient Programs (IOP): A structured program that maintains hours of service for at least nine (9) hours per week for adults and six (6) hours per week for children or adolescents during which assessment and diagnostic services, and active behavioral health treatment are provided. Outpatient: Assessment, diagnosis and active behavioral health treatment that are provided in an ambulatory setting, including individual and group counseling services. No benefits are available for psychosocial rehabilitation or care received as a custodial Inpatient. Residential Treatment Center Services (RTC): A hospital-based program which provides twenty-four (24) hours a day, seven (7) days a week nursing care, medical monitoring, and physician availability; assessment and diagnostic services, daily physician visits and active behavioral health treatment services for the purpose of initiating the process of assisting an Insured a Member with gaining the knowledge and skills needed to prevent recurrence of a mental health-related disorder. No benefits are available for psychosocial rehabilitation or care received as a custodial Inpatient. Evidence of Coverage NOTE: All non-routine, outpatient Mental Health or Severe Mental Illness Services require Prior Authorization. Insureds Members must call BHO at (000) 000-0000 or 0-000-000-0000 for assistance in scheduling their first appointment in order to verify that any requested Mental Health or Severe Mental Illness Services are Covered Services under the Plan, and that such Covered Services will be obtained at the appropriate level of care in order to be eligible for full benefit payment. A BHO coordinator will either assist in scheduling the appointment or will make a referral to the appropriate Plan Provider based on the service requested and the associated level of acuity. All inpatient Mental Health or Severe Mental Illness Services require Plan notification. Network facilities must provide notification of all inpatient admissions to the Plan. When these services are provided out of network, the Insured Member is responsible for providing the notification and relevant information to the Plan. Insureds Members should provide notice of emergent admissions within twenty-four (24) hours of admission or as soon as reasonably possible given the circumstances. The Insured Members may delegate their responsibility to provide notification to the non-network facility but it is the InsuredMember’s responsibility to ensure that the Plan receives notification. Initial notification results in a medical necessity review based on plan requirements and may result in an adverse benefit determination. All admissions for Emergency Services are reviewed Retrospectively retrospectively to determine if the treatment received was Medically Necessary and appropriate. If the Insured receives services other than Emergency Services in Member is admitted to a Mental Health or Severe Mental Illness facility for non-emergency treatment without obtaining Prior Authorization from SHLAuthorization, benefits Member will be reduced to 50% responsible for the cost of what the Insured would have received if the services had been Prior Authorized, provided however, that the benefits paid will not be less than 50% of the Eligible Medical Expenses. If the treatment received is not a Covered Service or if treatment is received for a condition which is not Medically Necessary, no benefit is payablereceived.