"Out-of-Network Intensive Outpatient Services" Horizon Blue Cross Blue Shield of New Jersey has established a new claim review process for out-of-network intensive outpatient services. Intensive outpatient programs are defined as having the capacity for planned, structured, service provision of at least two hours per day/three days per week. The range of services offered is designed to address a mental or a substance-related disorder and could include group, individual and/or family psychotherapy. HOW DOES THIS AFFECT YOU AS AN EMPLOYER?
The new review process will impact your employees and/or their dependents with Horizon POS and Horizon Direct Access who are receiving out-of-network services by health care professionals/facilities. Horizon BCBSNJ contracts with Magellan Behavioral Health (Magellan) for utilization management of certain behavioral health benefits, including intensive outpatient care. Intensive outpatient behavioral health benefits are available to your employees only when the services are medically needed and rendered at the appropriate level of care.
WHAT IS THE NEW REVIEW PROCESS AND WHEN IS IT EFFECTIVE?
Beginning April 1, 2008, if your employees, and/or their dependents are currently receiving, or planning to receive, out-of-network intensive outpatient behavioral health benefits, they are encouraged to have the behavioral health care professional/facility first call Magellan at 1-800-626-2212 to determine if services are medically necessary and are being provided at the appropriate level of care. The review process will then occur between the behavioral health care facility and Magellan as described below.
- A Magellan Care Manager will review the request and provide a determination of medical necessity. This process will allow the Magellan Care Manager to review the proposed course of treatment in advance, based on the clinical information provided and determine if and to what extent benefits will be payable under the applicable group plan.
- The review will provide an opportunity for the behavioral health care professional/facility and the Magellan Care Manager to work together to establish a plan that is appropriate for the member and maximize available benefits. The member and behavioral health care professional/facility will be notified of the outcome.
CONSEQUENCES FOR NOT FOLLOWING THE REVIEW PROCESS
If Magellan does not receive information from the behavioral health care professional/facility that is necessary to establish the medical necessity of services, or an unfavorable determination is made, employees and/or their dependents receiving services at out-of-network facilities may be financially responsible for all or a portion of the cost of the services, in accordance with the terms of their benefit plan. Intensive outpatient behavioral health benefits are only available when the services are medically necessary and rendered at the appropriate level of care.
HOW DO I MAXIMIZE MY PLAN BENEFITS?
To maximize Horizon POS and Horizon Direct Access plan benefits, we encourage your employees and/or their dependents to consider using a participating behavioral health care professional/facility. The participating behavioral health professional/facility will coordinate benefit eligibility directly with Magellan on the members' behalf.
PLEASE NOTE: Self-funded groups have the option to participate in this initiative and will only be included if they elect to do so. These groups should discuss this process with their respective sales representative or broker.
WHAT SHOULD I DO NEXT?
Please forward this information to your employees as soon as possible. If you have questions regarding the behavioral health care review process, or require additional information about this eCommunications, please contact Corporate Synergies at 1.866.CSG.1719, or click here to contact us today.
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