Outpatient Mental Health and Substance Abuse Services. Benefits are provided for Outpatient Facility and professional services for the diagnosis and treatment of Mental Health and Substance Abuse Conditions. These services may also be provided in the office, home, or other non-institutional setting. Non-Routine Outpatient Mental Health and Substance Abuse Services include, but may not be limited to, the following:
Outpatient Mental Health and Substance Abuse Services. Benefits are covered for outpatient services provided in a Contracting Physician’s office or in other Contracting Provider facilities. Covered Services include the following:
A. Diagnosis and treatment for Mental Illness and Emotional Disorders at Contracting Physician offices, other outpatient Contracting Provider medical offices and facilities, and in Qualified Partial Hospitalization Programs.
B. Diagnosis and treatment for Substance Abuse, including detoxification and rehabilitation services as an outpatient in a covered alcohol or drug rehabilitation program or Qualified Partial Hospitalization Program designated by CareFirst BlueChoice.
C. Other covered medical services and medical ancillary services for conditions related to Mental Illness, Emotional Disorders, and Substance Abuse.
D. Office visits for medication management in connection with Mental Illness, Emotional Disorders, and Substance Abuse.
E. Methadone maintenance treatment.
F. Partial Hospitalization in a Qualified Partial Hospitalization Program.
G. Electroconvulsive therapy.
Outpatient Mental Health and Substance Abuse Services. To be eligible for benefits, a Health Care Practitioner must certify that the Member is suffering from a Clinically Significant Mental Illness, Alcohol Abuse and/or Drug Abuse and prescribe Medically or Psychologically Necessary treatment (which may include referral to another Eligible Provider). Covered Services include:
A. Benefits are available for Outpatient Services (as described above) rendered by an Eligible Provider for the Medically or Psychologically Necessary treatment of Clinically Significant Mental Illness, Alcohol Abuse and/or Drug Abuse.
B. Benefits are available for Partial Hospitalization (as described above) services rendered in a Qualified Partial Hospitalization Program. Coverage for Partial Hospitalization is subject to CareFirst certification of the need and continued appropriateness of such services in accordance with CareFirst utilization management requirements.
C. Benefits are available for diagnosis and treatment for Alcohol Abuse and/or Drug Abuse, including outpatient detoxification and rehabilitative services in a covered alcohol or drug rehabilitation program or Qualified Partial Hospitalization Program. Members must meet the applicable criteria for acceptance into, and continued participation in, treatment facilities/programs, as determined by CareFirst.
D. Office visits for medication management in connection with Mental Illness, Alcohol Abuse and/or Drug Abuse will be covered on the same basis as other covered medical conditions.
Outpatient Mental Health and Substance Abuse Services. Outpatient services must be obtained from Contracting Providers upon referral from the Mental Health and Substance Abuse Management Program.
A. Coverage of mental illness, emotional disorders, drug abuse and alcohol abuse including psychological and neuropsychological testing for diagnostic purposes is provided. Services include evaluation, diagnosis and treatment of acute and non-acute conditions. The benefits for neuropsychological testing are not counted toward any outpatient mental health and substance abuse visit benefit.
B. Medication management visits in connection with mental illness, emotional disorders, alcohol abuse and drug abuse will be covered in the same manner as medication management visits for physical illnesses and will not be counted as outpatient mental health or substance abuse treatment visits. Prior authorization is not required for Methadone Maintenance Treatment and the Member does not need a referral from a Primary Care Physician.
C. Coverage of substance abuse and related mental health conditions includes detoxification and rehabilitative services in a CareFirst BlueChoice designated program.
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.
