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 SHL Behavioral Health. 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. All non-routine, outpatient Mental Health or Severe Mental Illness Services require Prior Authorization. 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 ambulatory program that may be freestanding or Hospital-based and provides services for at least 20 hours per week. 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 (RTC): a sub-acute facility or acute care facility which delivers twenty-four (24) hours/ seven (7) days a week assessment, diagnostic services and active behavioral health treatment to Insureds. The level of care and length of stay, in a facility with the appropriate licensure level, is authorized through the SHL Managed Care program. NOTE: Transitional Living services are not covered under RTC and are not a covered benefit. 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. The Insured should provide notice of emergent admissions within twenty-four (24) hours of admission or as soon as reasonably possible given the circumstances. 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 or the Recognized Amount when applicable. 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. Oral Physician Surgical Services Although dental services are not Covered Services, except as otherwise provide in the Attachment A Benefit Schedule, the following Oral Surgical Services are Covered Services: • Treatment for tumors and cysts requiring pathological examination of the jaws, cheeks, lips, tongue, roof and floor of the mouth. • Removal of teeth which are necessary in order to perform radiation therapy. • Treatment required to stabilize sound natural teeth, the jawbones, or surrounding tissues after an Injury (not to include injuries caused by chewing) when the treatment starts within the first ten (10) days after the Injury and ends within sixty (60) days from the date of Injury. Examples of Covered Services, in such instances, include:

Mental Health Services and Severe Mental Illness Services. All benefits are subject to the Utilization Management process through SHL Behavioral HealthHealthcare 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. All non-routine, outpatient Mental Health or Severe Mental Illness Services require Prior Authorization. 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 ambulatory program that may be freestanding or Hospital-based and provides services maintains hours of service for at least 20 twenty (20) hours per weekweek 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 subA hospital-acute facility or acute care facility based program which delivers provides twenty-four (24) hours/ hours a day, seven (7) days a week assessmentnursing care, medical monitoring, and physician availability, assessment and diagnostic services services, daily physician visits and active behavioral health treatment services for the purpose of initiating the process of assisting a Member with gaining the knowledge and skills needed to Insuredsprevent recurrence of a mental health-related disorder. The All non-routine, outpatient Mental Health or Severe Mental Illness Services require Prior Authorization. Member 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 and length of stay, in order to be eligible for full benefit payment. A BHO coordinator will either assist in scheduling the appointment or will make a facility with referral to the appropriate licensure level, is authorized through Plan Provider based on the SHL Managed Care program. NOTE: Transitional Living services are not covered under RTC service requested and are not a covered benefitthe 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. The Insured Member should provide notice of emergent admissions within twenty-four (24) hours of admission or as soon as reasonably possible given the circumstances. Insured Member may delegate their responsibility to provide Agreement of Coverage 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 the 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 or the Recognized Amount when applicable. 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. Oral Physician Surgical Services Although dental services are not Covered Services, except as otherwise provide in the Attachment A Benefit Schedule, the following Oral Surgical Services are Covered Services: • Treatment for tumors and cysts requiring pathological examination of the jaws, cheeks, lips, tongue, roof and floor of the mouth. • Removal of teeth which are necessary in order to perform radiation therapy. • Treatment required to stabilize sound natural teeth, the jawbones, or surrounding tissues after an Injury (not to include injuries caused by chewing) when the treatment starts within the first ten (10) days after the Injury and ends within sixty (60) days from the date of Injury. Examples of Covered Services, in such instances, include:received.

Mental Health Services and Severe Mental Illness Services. All benefits are subject to the Utilization Management process through SHL HPN Behavioral Health. 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. All non-routine, outpatient Mental Health or Severe Mental Illness Services require Prior Authorization. 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 ambulatory program that may be freestanding or Hospital-based and provides services for at least 20 hours per week. 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 (RTC): a sub-acute facility or acute care facility which delivers twenty-four (24) hours/ seven (7) days a week assessment, diagnostic services and active behavioral health treatment to InsuredsMembers. The level of care and length of stay, in a facility with the appropriate licensure level, is authorized through the SHL HPN Managed Care program. NOTE: Transitional Living services are not covered under RTC and are not a covered benefit. 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. The Insured Member should provide notice of emergent admissions within twenty-four (24) hours of admission or as soon as reasonably possible given the circumstances. Insured Member 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 the 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 or the Recognized Amount when applicable. 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. Oral Physician Surgical Services Although dental services are not Covered Services, except as otherwise provide in the Attachment A Benefit Schedule, the following Oral Physician Surgical Services are Covered Services: • Treatment for tumors and cysts requiring pathological examination of the jaws, cheeks, lips, tongue, roof and floor of the mouth. • Removal of teeth which are necessary in order to perform radiation therapy. • Treatment required to stabilize sound natural teeth, the jawbones, or surrounding tissues after an Injury (not to include injuries caused by chewing) when the treatment starts within the first ten (10) days after the Injury and ends within sixty (60) days from the date of Injury. Examples of Covered Services, in such instances, include:.

Mental Health Services and Severe Mental Illness Services. All benefits are subject to the Utilization Management process through SHL Behavioral HealthHealthcare 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. All non-routine, outpatient Mental Health or Severe Mental Illness Services require Prior Authorization. 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 ambulatory program that may be freestanding or Hospital-based and provides services maintains hours of service for at least 20 twenty (20) hours per weekweek 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 subA hospital-acute facility or acute care facility based program which delivers provides twenty-four (24) hours/ hours a day, seven (7) days a week assessmentnursing care, medical monitoring, and physician availability, assessment and diagnostic services services, daily physician visits and active behavioral health treatment services for the purpose of initiating the process of assisting a Member with gaining the knowledge and skills needed to Insuredsprevent recurrence of a mental health-related disorder. The All non-routine, outpatient Mental Health or Severe Mental Illness Services require Prior Authorization. Member 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 and length of stay, in order to be eligible for full benefit payment. A BHO coordinator will either assist in scheduling the appointment or will make a facility with Referral to the appropriate licensure level, is authorized through Plan Provider based on the SHL Managed Care program. NOTE: Transitional Living services are not covered under RTC service requested and are not a covered benefitthe 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. The Insured Member should provide notice of emergent admissions within twenty-four (24) hours of admission or as soon as reasonably possible given the circumstances. Insured Member 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 the 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 or the Recognized Amount when applicable. 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. Oral Physician Surgical Services Although dental services are not Covered Services, except as otherwise provide in the Attachment A Benefit Schedule, the following Oral Surgical Services are Covered Services: • Treatment for tumors and cysts requiring pathological examination of the jaws, cheeks, lips, tongue, roof and floor of the mouth. • Removal of teeth which are necessary in order to perform radiation therapy. • Treatment required to stabilize sound natural teeth, the jawbones, or surrounding tissues after an Injury (not to include injuries caused by chewing) when the treatment starts within the first ten (10) days after the Injury and ends within sixty (60) days from the date of Injury. Examples of Covered Services, in such instances, include:received.

Mental Health Services and Severe Mental Illness Services. All benefits are subject to the Utilization Management process through SHL Behavioral HealthHealthcare 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. All non-routine, outpatient Mental Health or Severe Mental Illness Services require Prior Authorization. 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 ambulatory program that may be freestanding or Hospital-based and provides services maintains hours of service for at least 20 twenty (20) hours per weekweek 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 subA hospital-acute facility or acute care facility based program which delivers provides twenty-four (24) hours/ hours a day, seven (7) days a week assessmentnursing care, medical monitoring, and physician availability, assessment and diagnostic services services, daily physician visits and active behavioral health treatment services for the purpose of initiating the process of assisting a Member with gaining the knowledge and skills needed to Insuredsprevent recurrence of a mental health-related disorder. The All non-routine, outpatient Mental Health or Severe Mental Illness Services require Prior Authorization. Member 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 and length of stay, in order to be eligible for full benefit payment. A BHO coordinator will either assist in scheduling the appointment or will make a facility with Referral to the appropriate licensure level, is authorized through Plan Provider based on the SHL Managed Care program. NOTE: Transitional Living services are not covered under RTC service requested and are not a covered benefitthe 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. The Insured Member should provide notice of emergent admissions within twenty-four (24) hours of admission or as soon as reasonably possible given the circumstances. Insured Member may delegate their responsibility to provide Agreement of Coverage 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 the 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 or the Recognized Amount when applicable. 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. Oral Physician Surgical Services Although dental services are not Covered Services, except as otherwise provide in the Attachment A Benefit Schedule, the following Oral Surgical Services are Covered Services: • Treatment for tumors and cysts requiring pathological examination of the jaws, cheeks, lips, tongue, roof and floor of the mouth. • Removal of teeth which are necessary in order to perform radiation therapy. • Treatment required to stabilize sound natural teeth, the jawbones, or surrounding tissues after an Injury (not to include injuries caused by chewing) when the treatment starts within the first ten (10) days after the Injury and ends within sixty (60) days from the date of Injury. Examples of Covered Services, in such instances, include:received.

Mental Health Services and Severe Mental Illness Services. All benefits are subject to the Utilization Management process through SHL HPN Behavioral Health. 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. All non-routine, outpatient Mental Health or Severe Mental Illness Services require Prior Authorization. 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 ambulatory program that may be freestanding or Hospital-based and provides services for at least 20 hours per week. 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 (RTC): a sub-acute facility or acute care facility which delivers twenty-four (24) hours/ seven (7) days a week assessment, diagnostic services and active behavioral health treatment to InsuredsMembers. The level of care and length of stay, in a facility with the appropriate licensure level, is authorized through the SHL HPN Managed Care program. NOTE: Transitional Living services are not covered under RTC and are not a covered benefit. 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. The Insured Member should provide notice of emergent admissions within twenty-four (24) hours of admission or as soon as reasonably possible given the circumstances. Insured Member 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 the 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 or the Recognized Amount when applicable. 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. Oral Physician Surgical Services Although dental services are not Covered Services, except as otherwise provide in the Attachment A Benefit Schedule, the following Oral Physician Surgical Services are Covered Services: •  Treatment for tumors and cysts requiring pathological examination of the jaws, cheeks, lips, tongue, roof and floor of the mouth. •  Removal of teeth which are necessary in order to perform radiation therapy. • Treatment required to stabilize sound natural teeth, the jawbones, or surrounding tissues after an Injury (not to include injuries caused by chewing) when the treatment starts within the first ten (10) days after the Injury and ends within sixty (60) days from the date of Injury. Examples of Covered Services, in such instances, include:.