Coverage UDPATE—Mental Health and Substance Use Disorder

MEDICAL PROVIDERS: Please review these updated 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
     
     
2. 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.
   
   
3. Psychotherapy visits are covered without pre-authorization. Initial therapy should be started after a physician evaluation and with physician orders.
   
   
4. After initial 15 visits, subsequent therapy visits can be performed only with an individualized written treatment plan signed by a psychiatrist, a psychiatric APRN, or if neither of these is available, a primary care physician.
   
   
5. 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.
     
     
6. Frequency and duration of services must be reasonable.
   
   
7. Treatment plan as well as required psychiatrist/APRN/PCP evaluation and order must be available for retrospective record review by Care Management if requested.
   
   
8. 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.
   
   
9. A provider visit solely with the member’s family (except for the legal guardian) is not covered.

View complete Medical Coverage Policy here. 

QualChoice may review medical records at any time. Services not meeting above requirements or medical necessity criteria as described in the medical policy statement of the policy, will be denied retrospectively.