Prior authorization request form Form

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 PAYMENT POLICY | 1 (401) 274-4848 WWW.BCBSRI.COM

EFFECTIVE DATE: 11|01|2024 POLICY LAST REVIEWED: 10|02|2024

OVERVIEW The intent of this policy is to provide information regarding the supervisory protocol for Licensed Clinical Social Workers (LCSWs), Postdoctoral clinicians, Mental Health Counselor Associates (MHC- As), Marriage and Family Therapist Associates (MFT-As), and Physician Assistants (PAs) having the ability to render services under a supervising independently-licensed behavioral health clinician who is credentialed with Blue Cross & Blue Shield of Rhode Island (BCBSRI).

MEDICAL CRITERIA Not applicable

NOTIFICATION OF ADMISSION
Not applicable

POLICY STATEMENT BCBSRI has implemented a supervisory protocol process whereby Licensed Clinical Social Workers (LCSWs), Postdoctoral clinicians, Mental Health Counselor Associates (MHC-As), Marriage and Family Therapist Associates (MFT-As), and Physician Assistants (PAs) may render services to our members in a professional outpatient setting under the supervision of an independently-licensed behavioral health clinician. BCBSRI does not credential LCSWs, Postdoctoral clinicians, MHC-As, or MFT-As.

Professional outpatient providers who are credentialed with BCBSRI must have a written policy addressing the following requirements of the supervisory protocol:
a. Documentation the supervising clinician is credentialed with BCBSRI b. A clear process for informing the patient that a clinician who is not credentialed with BCBSRI is providing the service to them and documentation of the patient’s awareness of same c. Process by which documentation of the patient’s overall treatment (assessment, treatment plan, and any changes to the diagnosis) is reviewed by the supervising BCBSRI-credentialed provider(s). d. A process that supports the supervisor(s) and the supervisee meeting on a regular basis, in accordance with the Rhode Island Department of Health guidelines.

Member’s medical records must document that services are medically necessary for the care provided and comply with BCBSRI rules, regulations, policies and procedures. BCBSRI maintains the right to audit the services provided to our members, regardless of the participation status of the provider. All documentation must be available to BCBSRI upon request. Failure to produce the requested information within 30 days may result in denial or retraction of payment.

Supervisory Protocol Reference Table
Supervisee Supervisor Licensure that bills
Licensed Clinical Social Worker (LCSW) Licensed Independent Clinical Social Worker (LICSW) Licensed Independent Clinical Social Worker (LICSW) Post Doctoral Clinician Licensed Psychologist Licensed Psychologist Payment Policy | Behavioral Health Supervisory Protocol for Licensed Clinical Social Workers, Postdoctoral Clinicians, Mental Health Counselor Associates, and Marriage and Family Therapist Associates

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 PAYMENT POLICY | 2 (401) 274-4848 WWW.BCBSRI.COM

Mental Health Counselor Associate (MHC-A) Licensed Mental Health Counselor (LMHC) Licensed Psychiatrist Licensed Psychologist Licensed Marriage and Family Therapist (LMFT) Licensed Independent Clinical Social Worker (LICSW) Licensed Mental Health Counselor (LMHC) Licensed Psychiatrist Licensed Psychologist Licensed Marriage and Family Therapist (LMFT) Licensed Independent Clinical Social Worker (LICSW) Marriage and Family Therapy Associate (MFT-A) Licensed Marriage and Family Therapist (LMFT) Licensed Marriage and Family Therapist (LMFT) Physician Assistant working towards a specialization in behavioral health Physician Assistant – Behavioral health (PA-BH) Licensed psychiatrist within a behavioral health setting Physician Assistant – Behavioral health (PA-BH) Licensed psychiatrist within a behavioral health setting

For more information, please contact BCBSRI Behavioral Health Utilization Management at behavioralhealth@bcbsri.org

COVERAGE Benefits may vary between groups/contracts. Please refer to the appropriate Evidence of Coverage or Subscriber Agreement for applicable behavioral health services for benefits and applicable deductibles and/ or co-payments. Services may be rendered to Commercial and Medicare Members. Per CMS Chapter 15 of the Medicare Benefit Policy Manual which indicates: “Direct supervision in the office setting does not mean that the physician must be present in the same room with his or her aide. However, the physician must be present in the office suite and immediately available to provide assistance and direction throughout the time the aide is performing services.”

CODING Unless specified in a specific payment policy, BCBSRI follows correct coding and payment guidelines published by National and Regional CMS (including DMEMAC) and other correct coding national standards such as Current Procedural Terminology (CPT). Please refer to the Coding and Payment Guidelines policy for additional details. All services rendered should be in accordance with correct coding.

Claims must be submitted by the independently licensed BCBSRI-credentialed clinician and must include an HO modifier to indicate services rendered by an LCSW, MHC-A, or MFT-A; an HP modifier to indicate services rendered by a Post Doctorate Clinician; or an HN modifier to indicate services rendered by a Physician Assistant (please refer to payment policy for Behavioral Health Outpatient Professional Services for CPT codes). i RELATED POLICIES Autism Spectrum Disorders Mandate Behavioral Health Outpatient Professional Services Coding and Payment Guidelines Health and Behavior Assessment
Preventive Services for Commercial Provider Credentialing and Recredentialing Policy

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 PAYMENT POLICY | 3 (401) 274-4848 WWW.BCBSRI.COM

Psychological and Neuropsychological Testing Telemedicine Services for Commercial Products Telemedicine Services for Medicare Advantage
Transcranial Magnetic Stimulation

PUBLISHED Provider Update, February/July/October 2024 Provider Update, April 2023 Provider Update, July 2022 Provider Update, August 2021

REFERENCES None ii

This medical policy is made available to you for informational purposes only. It is not a guarantee of payment or a substitute for your medical judgment in the treatment of your patients. Benefits and eligibility are determined by the member's subscriber agreement or member certificate and/or the employer agreement, and those documents will supersede the provisions of this medical policy. For information on member-specific benefits, call the provider call center. If you provide services to a member which are determined to not be medically necessary (or in some cases medically necessary services which are non-covered benefits), you may not charge the member for the services unless you have informed the member and they have agreed in writing in advance to continue with the treatment at their own expense. Please refer to your participation agreement(s) for the applicable provisions. This policy is current at the time of publication; however, medical practices, technology, and knowledge are constantly changing. BCBSRI reserves the right to review and revise this policy for any reason and at any time, with or without notice. Blue Cross & Blue Shield of Rhode Island is an independent licensee of the Blue Cross and Blue Shield Association.

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