Coverage Guidelines—Mental Health and Substance Use Disorder

November 28, 2018
Coverage Guidelines—Mental Health and Substance Use Disorder

MEDICAL PROVIDERS: Please review these guidelines for our Outpatient Therapy for Mental Health & Substance Use Disorder medical coverage policy (BI273).

  1. Mental health therapies require:
    • A valid diagnosis
    • An evidence-based treatment plan
    • Periodic re-evaluation of the treatment’s success
    • Adjustments in treatment based on effectiveness
  1. Therapy services must be prescribed by a physician. If no direct or telemedicine psychiatric evaluation is available, a psychiatric APRN (with a collaborative practice agreement with a psychiatrist) can fulfill this role. If neither a psychiatrist nor a psychiatric APRN is available, a primary care physician is acceptable.

  2. First 15 psychotherapy visits are covered without pre-authorization. Pre-authorization and a psychiatrist’s individualized written treatment plan are required after initial 15 visits.

  3. Medically necessary psychotherapy services must be:
    • Considered appropriate and needed for the treatment of the disabling or impairing condition.
    • Related to a written treatment plan and be restorative, not palliative or habilitative in nature, or be for the purpose of designing a maintenance program to help the patient cope with psychological problems.
    • Of a level of complexity that requires the judgment, knowledge and skills of a licensed therapist.
  1. Frequency and duration of services must be reasonable.

  2. Treatment plan must be available for review by Care Management if requested.

  3. One diagnostic evaluation by a psychiatrist per member is covered every 12 months. Any additional psychiatric diagnostic evaluations by the same provider within 12 months require pre-authorization.

  4. A provider visit solely with the member’s family (except for the legal guardian) is not covered.

View complete BI273 Medical Coverage Policy here.