CAM 365

Behavioral Health Guidelines

Category:Mental Health   Last Reviewed:May 2019
Department(s):Medical Affairs   Next Review:May 2999
Original Date:January 1975    

Description:
Treatments for behavioral health conditions are reimbursed according to the patient’s specific contract benefit language. There are instances, however, where a patient may be treated for a medical condition that is related to or caused by a behavioral health condition or may receive specialized medical services for a behavioral health condition.


Policy:
Medical Treatment Related to Behavioral Health Conditions

If a patient is treated for a medical condition that is related to or caused by a behavioral health condition, the services rendered must be primarily for the treatment of the medical condition, and the primary diagnosis must be for the physical condition in order for benefits to be reimbursed under the medical portion of the contract. Specialized medical services for behavioral health conditions will be reimbursed under the medical portion on the contract, but will be coordinated with established behavioral health clinical guidelines.

Medical services such as surgery, fracture reduction, blood replacement, speech/physical/occupational therapies or medical treatment to improve the vital signs, would be reimbursed according to the contract’s medical services provision. Services following the stabilization for the behavioral health condition would then be reimbursed according to the behavioral health benefits.

When there is a question concerning the primary diagnosis, a review request should be initiated to Health Care Services (HCS) or Companion Benefit Alternatives (CBA). CBA is a seperate company that manages behavioral health and substance abuse benefits for members on behalf of this health plan. HCS and CBA case managers will coordinate efforts to determine the appropriate benefit adjudication.

SUBSTANCE USE DISORDER AND REHABILITATION GUIDELINES:
Substance Use Disorder is the overuse, misuse or dependency on drugs or alcohol. Substance Use Disorder may be related to legal or illegal, prescription or over-the-counter drugs or a combination of several. There are two treatment phases:

  • Detoxification (Detox): Reduction of the toxic properties of a substance by chemical changes induced in the body, producing a compound that is less poisonous or is more readily eliminated. Medical management is typically required for treatment of the characteristic and, at times, potentially dangerous physiological symptoms caused by the abrupt cessation of substances known to cause physical dependency and withdrawal. Typical substances that cause physical dependency/significant physiologic withdrawal requiring medical management are alcohol, sedative/hypnotics and barbiturates.
  • Rehabilitation (Rehab) for Substance Abuse: The treatment phase of addictions to drugs and/or alcohol with emphasis on recovery and abstinence usually occurs in an outpatient ambulatory setting. For contracts that have no provision for rehab, it may be necessary to refer the case to medical review to ascertain which portion of the claim is related to detoxification. Benefits for the treatment of substance abuse, whether detoxification and/or rehabilitation, are subject to the provisions of the specific contract.
  • CBA is committed to monitoring Federal Parity legislation for current guidelines and ensuring appropriate benefit management compliance. CBA will work with health plans regarding regulatory requirements.

**PLEASE SEE SPECIFIC CONTRACT FOR EXCLUSIONS AND PRECERTIFICATION REQUIREMENTS. REFERENCE TO CBA IS ONLY APPLICABLE WHEN CBA MANAGES THE BEHAVIORAL HEALTH BENEFITS.**

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross and Blue Shield Association technology assessment program (TEC) and other non-affiliated technology evaluation centers, reference to federal regulations, other plan medical policies and accredited national guidelines.

"Current Procedural Terminology© American Medical Association.  All Rights Reserved" 

History From 2014 Forward     

05/08/2019 

Annual review, no change to policy intent.

05/02/2018 

Annual review, no change to policy intent. 

05/16/2017 

Annual review. No change to policy intent.

05/02/2016 

Annual review, removing opioids from the last sentence in the detoxification paragraph. 

05/11/2015 

Content changes by request of CBA, no change to policy intent. 

05/05/2014

Annual review. One sentence removed per request of CBA in the description of detoxification. No change to policy intent  


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