The BEH department uses United Behavioral Health (UBH) Level of Care criteria in determining medical necessity of inpatient psychiatric, partial hospitalization substance abuse treatment and rehabilitation, and outpatient mental health treatment. In addition, Medicare coverage guidelines are utilized for MedicareComplete® members.
Inpatient mental health
A mental health condition is defined as justifying inpatient (or acute) care when it involves a sudden and quickly developing clinical situation characterized by a high level of distress and uncertainty of outcome without intervention. Examples include:
The patient has been unresponsive to an appropriate
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course of treatment at a lower level of care and is at significant risk.
The patient is considered a serious risk to self or others
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and requires 24-hour supervision.
The patient is unable to maintain a safe environment for
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self or others.
Partial hospitalization – mental health
Partial hospitalization* for mental health treatment is defined as day treatment of a psychiatric disorder at a hospital or ancillary facility with the following criteria:
Primary diagnosis is psychiatric
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The facility is licensed and accredited to provide
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such services
The duration of each treatment is four (4) or more hours
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per day
* Partial hospitalization is only available to members with this benefit.
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Residential treatment
Residential treatment services are provided in a facility or a freestanding residential treatment center that provides overnight mental health services for members who do not require acute inpatient care but who do require 24-hour structure.
This benefit is subject to precertification and ongoing medical necessity reviews. Each state has different requirements and benefits should be reviewed. Outpatient mental health
A psychotherapeutic outpatient treatment is defined as a range of approaches for the treatment of mental and emotional disorders that include methods from different theoretical orientations (i.e., psychodynamic, behavioral, cognitive, and interpersonal) and may be administered to an individual, family or group. Examples include:
The primary diagnosis/focus of treatment is for a
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psychiatric condition and is not related to substance abuse or dependence.
The diagnosis or service is not a benefit exclusion (e.g.,
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sexual disorders, marital counseling, etc.).
The primary diagnosis is not identified as a V-code – any
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diagnosis beginning with a V indicates wellness and is not considered a psychiatric diagnosis.
Treatment is focused on restoring or maintaining function
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that has been compromised due to mental illness. Treatment is goal-oriented and directed to achieve
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specific outcomes.
Please note: Under NCQA guidelines and requirements, we strongly support coordination of care between
behavioral health physicians and primary care physicians (PCPs). With input from the BEH Quality Improvement Committee, we have developed a Release of Information (ROI) form to facilitate the sharing of treatment information between BEH physicians and PCPs. This form is
designed to elicit member consent to such sharing of information in the presence of his or her behavioral health physician. This form may be downloaded from our website, www.oxfordhealth.com> Tools and Resources> Forms.
Inpatient detoxification
Inpatient detoxification is defined as the treatment of substance dependence to prevent a life-threatening withdrawal syndrome, provided on an inpatient basis.
Conditions under which inpatient detoxification is medically indicated include:
The patient is a risk to self and others.
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The patient’s medical status is altered by withdrawal
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syndrome that requires 24-hour monitoring.
A licensed physician (MD or DO) is available on-site 24
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hours per day.
The DSM-V diagnosis indicates psychoactive
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substance dependence.
The facility is a licensed, accredited detoxification facility.
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Outpatient substance abuse rehabilitation
Outpatient substance abuse rehabilitation is defined as the treatment of substance abuse or dependence at an accredited, licensed substance abuse facility. Conditions under which outpatient substance abuse rehabilitation is medically indicated include:
The primary diagnosis and focus of substance abuse
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treatment is within the DSM-IV range of 303-305. An evaluation by a licensed substance abuse physician
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has resulted in certification by our BEH department. Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA)
As of July 1, 2010, for certain new and renewing groups, benefits are subject to final regulations supporting the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA). Benefits for mental health conditions and substance use disorder conditions that are covered services must be treated in the same manner and be provided at the same level as covered services for the treatment of any other illness or injury.
MHPAEA requires that the financial requirements for coinsurance and copayments for mental health and substance use disorder conditions must be no more restrictive than those coinsurance and copayment
requirements for substantially all medical/surgical benefits. Changes that result from MHPAEA also affect both prior authorization requirements and excluded services. Prior authorization requirements no longer apply for outpatient mental health and substance abuse services. Exclusions for mental health conditions and substance use disorders that were specific to these conditions, but that were not applicable to other sickness or medical conditions, no longer apply.
Please note: MHPAEA applies to fully insured and self- funded plans that have 50 or more total employees.
Groups that are not subject to MHPAEA may be subject to state parity legislation, which is summarized on the following pages.
New Jersey mental health parity (for commercial members)
The State of New Jersey has enacted Biologically Based Mental Health Parity legislation (P. L. 1999, c. 106) that states that biologically based mental illness must be covered under the same terms and conditions as all other medical illnesses and diseases.
The law defines biologically based mental illness as a mental or nervous condition that is caused by a biological disorder of the brain and results in a clinically significant or psychological syndrome or pattern that substantially limits the functioning of the person with the illness including, but not limited to, schizophrenia, schizoaffective disorder, major depressive disorder, bipolar disorder, paranoia and other psychotic disorders, obsessive-compulsive disorder, panic disorder, and pervasive developmental disorder or autism.
This law does not affect coverage for substance abuse or for mental illness that is not biologically based. These latter conditions include mental retardation, learning disorders, motor skills disorder, communication disorders, caffeine- related disorders, relational problems, and additional conditions that may be a focus of clinical attention, but which are not otherwise defined as mental disorders in the most recent edition of the American Psychiatric
Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM) referenced in this section.
The New Jersey law does not affect Medicare plans. In addition, it does not affect medical necessity, certification or referral requirements. New Jersey members should check their Certificate of Coverage for certification and referral requirements.
Connecticut mental health parity (for commercial members)
Connecticut has also enacted Mental Health Parity legislation (Managed Care Act – Public Act No. 99-284). The law states that all Connecticut commercial group products will be required to provide benefits for the diagnosis and treatment of mental or nervous conditions under the same terms and conditions as all other illnesses and diseases.
For purposes of this legislative requirement, mental or nervous conditions means mental disorders, as defined in the most recent edition of the American Psychiatric
Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM). The definition does not include mental retardation, learning disorders, motor skills disorder, communication disorders, caffeine-related disorders, relational problems, and additional conditions that may be a focus of clinical attention that are not otherwise defined as mental disorders in the DSM referenced above.
Please note: Parity is also required for disorders related to the complications of alcohol and substance abuse, as defined in the DSM. The Connecticut law does not affect self-funded plans or Medicare plans. In addition, it does not affect medical necessity, precertification or
referral requirements.
New York mental health parity (for commercial members)
As of January 1, 2007, for new and renewing groups, legislation was enacted in New York mandating broad- based coverage for the diagnosis and treatment of mental, nervous, or emotional disorders and ailments. Previously, coverage of mental illness was only a “mandated offer.” Additionally, treatment for biologically based illness and treatment for Children with Serious Emotional
Disturbances is mandated for large groups on a parity basis. “Parity” means the benefit must be equal to the coverage provided for other health conditions (i.e., mental health benefits cannot have a higher cost share than is required for other medical services or contain day or visit limits that are lower than medical services). Small groups may elect to purchase this additional level of coverage. The coverage varies depending on the size of the group and the type of policy. This does not apply to the self- funded, Healthy NY and individual plans.
Mental health services
For purposes of this mandate, “mental, nervous or emotional disorders or ailments” means medically necessary care rendered by an eligible practitioner or approved facility which, in our opinion, is directed predominantly at treatable behavioral manifestations of a condition that we determine:
is a clinically significant behavioral or psychological
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syndrome, pattern, illness or disorder; and
substantially or materially impairs a person’s ability to
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function in one or more major life activities; and has been classified as a mental disorder in the current
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American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders.
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Outpatient mental health services
Covered services are those received on an outpatient basis from duly licensed psychiatrists or practicing psychologists, certified social workers, or a facility issued operating certificate by the commissioner of mental health, a facility operated by the office of mental health, a
professional corporation or university faculty practice corporation including: Diagnosis ■ ■ Treatment planning ■ ■ Referral services ■ ■ Medication management ■ ■ Crisis intervention ■ ■
Coverage will be provided to the maximum number of visits shown on the member’s Summary of Benefits.
Please note: Visits for biologically based services will count toward this limit.
Inpatient mental health services
Covered services are received on an inpatient or partial hospitalization basis in a facility as defined by subdivision 10 of section 1.03 of the mental hygiene law, as well as by any other network physician or other health care
professional we deem appropriate to provide the medically necessary level of care.
If an inpatient stay is required, it is covered on a semi- private room basis. If partial hospitalization is precertified, two partial hospitalization visits may be substituted for one inpatient day. Coverage will be provided for active
treatment to the maximum number of days shown on the member’s Summary of Benefits.
Please note: Visits for biologically based services will count toward this limit. Active treatment means treatment furnished in conjunction with inpatient confinement for mental, nervous or emotional disorders or ailments that meet standards prescribed pursuant to the regulations of the commissioner of mental health.