Behavioral Health and Substance Use Disorder (SUD) Services

Behavioral Health and Substance Use Disorder (SUD) services are managed by Harvard Pilgrim Health Care. This includes:

• Credentialing and re-credentialing of behavioral health and SUD providers
• Utilization management (including prior authorization) of behavioral health and SUD benefits
• Behavioral health and SUD provider network development and management
• Administration of behavioral health and SUD benefits, including member services
• Claims processing

For general information on prior authorization (including how to submit an authorization request and information required), please refer to the Prior Authorization Policy.

Crisis Assessment

A mental health crisis is an intensive behavioral, emotional, substance use, or psychiatric situation which, if left untreated, could result in an emergency situation.

In a Behavioral Health crisis, neither a referral from the PCP, nor prior authorization from Harvard Pilgrim is required for a crisis (i.e., emergency) assessment (pre-admission evaluation). After the evaluation, contact Harvard Pilgrim Health Care to obtain assistance with admissions to alternative level of care settings, and/or the coordination of behavioral health care.

Emergency Care

Harvard Pilgrim covers emergency services that are medically necessary to screen and stabilize members in a behavioral health/SUD emergency. Members who believe they are having a behavioral health/SUD emergency are encouraged to seek care at the nearest emergency facility. Neither a referral from the PCP or authorization from Harvard Pilgrim are required. Admitting hospitals are responsible for notifying Harvard Pilgrim within the following notification timeframes.

• Urgent/emergent acute behavioral health admissions must be reported within 72 hours by facilities in Massachusetts.
• Urgent/emergent acute behavioral health admissions must be reported within two (2) business days by facilities in all other states.

Prior authorization is not required for post-stabilization services at an acute (24-hour) level of care facility following an Emergent Inpatient Behavioral Health/SUD Admission.

HARVARD PILGRIM HEALTH CARE-PROVIDER MANUAL

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September 2023

Harvard Pilgrim Health Care a Point32Health company

Referral, Notification, and Authorization-Notification

Alternative to Hospital Programs

Prior authorization is required before Harvard Pilgrim members are admitted to any alternative programs for the treatment of psychiatric condition or substance use disorder. Alternatives to behavioral health and substance use disorder hospitalization include:

• Partial hospitalization program (PHP)

Alternative program stays are reviewed concurrently to evaluate the on-going medical necessity of continued treatment, and to identify opportunities for timely discharge planning.

Outpatient Services

Prior Authorization through the Behavioral Health Department

Prior authorization is required for some outpatient behavioral health services, including but not limited to the following:

• Transcranial Magnetic Stimulation (rTMS)
• Psychological and Neuropsychological Testing
• Applied Behavioral Analysis (ABA)
• Non-urgent/non-emergent services out-of-network (for plans without coverage out of network)
• Some Behavioral Health for Children & Adolescents services, such as In-Home Therapy Services and In-Home Behavioral Services

To request authorization for a service requiring prior authorization through the behavioral health department, the treating provider should refer to the appropriate medical necessity guidelines for medically necessary criteria and prior authorization submission instructions. In the rare instance that an HMO member requires non-urgent/non-emergent services by a provider who does not participate in the Harvard Pilgrim network, prior authorization is required by Harvard Pilgrim Health Plan. For more information, refer to the medical necessity guidelines for Out-of-Network Coverage at the In-Network Level of Benefits.

Providers can also call the Provider Service Center at 800-708-4414 for further information.

*Massachusetts Plans Only

Under a POS or PPO plan, prior authorization is not required for ATS or CSS from either a plan provider or non-plan provider. ATS/CSS services provided beyond the first 14-day period may be subject to concurrent review under the terms of the member’s plan. Providers should notify the Behavioral Access Center within 48 hours of an admission for ATS/CSS, however coverage will not be denied for the first 14 days of ATS/CSS for failure to notify. For Substance Use Disorder treatment services other than ATS/CSS, prior authorization is not required when provided by a provider certified or licensed by the Massachusetts Department of Public Health.

PUBLICATION HISTORY

1. 01/01/12 removed First Seniority Freedom information from header
2. 02/15/12 minor edit for clarity
3. 03/15/12 updated authorization information for non-emergent inpatient behavioral health admissions; updated referral information for outpatient services
4. 06/15/12 added notification information; added crisis assessment section
5. 05/15/13 added authorization requirements for non-routine outpatient services
6. 10/15/13 added transcranial magnetic stimulation for major depression to outpatient services
7. 10/01/15 added substance abuse treatment authorization and notification information effective 10/01/15
8. 01/09/19 added online resources information and clarified authorization and referral requirements; added information for Massachusetts plans only
9. 07/10/20 changed UBH to Optum and substance abuse to substance use disorder (SUD) throughout; clarified extended outpatient treatment visits requirements; added information excluding all Massachusetts fully insured plans.
10. 09/15/22 added new Section, Maine Requirements for Management of Behavioral Health Benefits for Members Aged 21 Years or Younger, to incorporate regulatory requirements of 2021 Maine House Paper 1416, An Act to Improve Children’s Mental Health by Requiring Insurance Coverage for Certain Mental Health Treatment.
11. 09/01/23 updated for behavioral health insourcing effective on 11/01/23

HARVARD PILGRIM HEALTH CARE-PROVIDER MANUAL

D.22
September 2023

Harvard Pilgrim Health Care a Point32Health company

Referral, Notification, and Authorization-Notification

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September 2023