Utilization Review

CBHA Outpatient Services

The enrollee or network provider shall call 1-800-475-7900 to initiate registration for outpatient treatment. If the enrollee requests a specific network provider, or the call is from the network provider's office, a CBHA Customer Service Representative or Clinical Case Manager will verify enrollee eligibility and benefits and will complete an initial registration. No patient is ever denied access to outpatient services.

If the enrollee needs a referral to a network provider, the CBHA Clinical Case Manager will conduct a brief telephone assessment in order to match the patient with the most appropriate provider to assure the patient receives the right care at the right time by the right provider.

If it is determined that an emergent situation exists, the Clinical Case Manager will follow the crisis protocol and shall direct the patient to the nearest facility equipped to handle the crisis/emergency.

If the patient is seeking outpatient treatment and no crisis exists, the enrollee is given a choice of at least three appropriate in-network providers or the enrollee may request a specific network provider. Once the enrollee chooses a provider, an initial registration is issued for twenty sessions of outpatient therapy or unlimited sessions for medication management to a Psychiatrist or Nurse Practitioner. If more than twenty outpatient psychotherapy sessions are needed the provider must call the CBHA Clinical Care Manager at 1-800-475-7900 to substantiate medical necessity.

All in-network outpatient services except for emergencies must be registered by Carolina Behavioral Health Alliance in advance of receiving these services so that care can be coordinated and to prevent concurrent care by two like providers. Emergency services must be authorized within 72 hours or the next business day, whichever is later, following the beginning of services.

Except for emergencies, failure to register outpatient services will result in the provider not getting paid but the patient must be held harmless and can only be charged their relevant in-network copay or coinsurance.

Services Requiring Prior Authorization

All intensive levels of services (inpatient, partial hospitalization, intensive outpatient programs) require prior authorization as well as the following outpatient services:

Psychological and Neuropsychological Testing

Extended Therapy Sessions (90808 & 90809)

Behavioral Health Home Visits

Outpatient ECT

Outpatient Suboxone Treatment and Therapy

Outpatient Consultations

Gastric Bypass Evaluations

* Please note that individual Health Plans continue to have behavioral health exclusions. If you have questions regarding these exclusions, please call CBHA at 800-475-7900.

Access and Triage

CBHA is committed to ensuring that its network includes sufficient numbers of providers representing the full range of disciplines, and that geographic distributions are adequate to the needs of its enrollees.

The National Committee for Quality Assurance (NCQA) has established the following accessibility standards; all CBHA network providers are expected to meet these standards:

• Immediate access upon referral for life-threatening emergent cases;
• Emergent appointments within 4 hours;
• Urgent appointments within 24 hours;
• Routine appointments within 5 to 10 business days.

Network providers are required to immediately notify CBHA if they are unable to meet the accessibility standards listed above.

All network providers are required to have an emergency on-call system to assure that their patients have access to care 24-hours a day, 7 days a week.

A CBHA clinician is available for emergencies 24-hours a day, 7 days a week through a call-in process at 1-800-475-7900. The Clinical Case Manager will complete a telephone triage, refer the enrollee to the appropriate level of treatment and authorize initial treatment. An inpatient 23-hour observation bed admission may be authorized for some patients until a more complete assessment is completed and a treatment plan is formulated.

The CBHA authorization process is designed to ensure a timely response to requests for service. CBHA uses seven core criteria in determining medical necessity for any given level of service:

• Services are necessary and appropriate for the diagnosis, evaluation or treatment of a mental health or substance abuse condition or illness other than mental retardation, with a distinct diagnosis as given in the most recently-published edition of the Diagnostic & Statistical Manual of Mental Disorders.

• Services can reasonably be expected to improve the enrollee's condition or level of functioning or at least prevent further deterioration.
• The services are provided at the level of care appropriate to the severity of the enrollee's illness and capacity to respond to professionally provided treatment.
• The services are consistent with generally accepted standards of behavioral health professional practice in the community.
• The services are provided within the professional competence of the provider.
• The services are not for experimental, investigational or cosmetic purposes.
• The services are not solely for the convenience of the enrollee, enrollee's family or the provider.

If the presence of medical necessity is in doubt, the CBHA Medical Director or Assistant Medical Director will be consulted.

Carolina Behavioral Health Alliance Responsibilities

CBHA has the responsibility to:

• Obtain all information required to make the clinical case management decision including pertinent clinical information.
• Provide enrollees and their network providers with toll-free telephone access to clinical case management staff twenty-four hours per day/seven days per week for required pre-authorization.
• Limit information requests to information necessary to certify the service in question.
• Provide notification of clinical case management decisions within 72 hours of receipt of all necessary information (authorizations communicated to network providers; non-certifications communicated to network providers; written or electronic confirmation communicated to the enrollee).

Non-Authorizations for Concurrent Inpatient Reviews: In instances where a non-authorization determination is made, CBHA remains responsible for covered behavioral health services until the network provider and/or the enrollee has been notified of the non-authorization. Notification to the enrollee may be through hospital staff, physician or CBHA's clinical case management staff.

Requests for Continued Outpatient Services

Requests for more than 20 psychotherapy sessions, within an episode of care, will require the treating provider to complete the “Outpatient Services Review” form, which can be found on our website.  This form must be submitted to a CBHA Clinical Care Manager, who will review for medical necessity and will issue an authorization, accordingly.  (See appendix: medical necessity criteria for continued outpatient services). 

Some of the information that must be documented on the “Outpatient Services Review Form” includes:

1. Current DSM-IV Axial Assessments;
2. Clinical Global Impressions for Severity of Illness and Global Improvement;
3. Focus of Current Treatment
4. Risk Factors
5. Number of visits requested;
6. Coordination of care with other medical/behavioral health providers
7. Factors Preventing Closure of Treatment

When a new authorization is issued for continued services, the new authorization overrides any previous authorization for that enrollee. Previously authorized sessions with the provider that have not been used are no longer valid; only one registration/authorization number is valid at any given time.

Once the information is received and reviewed by CBHA clinical care management staff, the following authorization decisions may be made:

Authorization of Continued Outpatient Services: If the treatment documentation justifies medical necessity and reflects appropriate care within the appropriate time frame, an authorization is issued on the date the information is received; an authorization letter is sent to the enrollee and provider within 72 hours. Any prior authorization or registration to that provider is terminated on the date the new authorization is issued.

Authorization with Specific Request: When information is received that documents medical necessity, however does not document adequate justification for the number of visits requested, the Clinical Care Manager may authorize a portion of the visits requested. A letter is sent within 72 hours of receipt of the decision specifying the number of authorized visits and identifying the specific areas that need to be addressed in order to approve additional visits.

Non-Authorization of Continued Services: A non-authorization letter is initiated in the following cases:

1. Failure to meet medical necessity;
2. The enrollee already has an authorization for another provider for the same level of care/service;
3. The requested service is not a covered benefit.

The non-authorization letter is sent to the provider and the enrollee within 72 hours of the request for coverage; this letter specifies the reason(s) services could not be authorized. The appeal process is available only for non-authorizations for failure to meet medical necessity, and the letter will identify the appeal process. The other reasons listed above for non-authorization are not eligible for the appeal process. The CBHA Medical Director or Assistant Medical Director makes all non-authorization decisions for failure to meet medical necessity criteria.

Questionable Medical Necessity: In the event provider information leaves any questions of medical necessity, the clinical care manager is responsible to notify the CBHA Medical Director/Assistant Medical Director for consultation and direction. The Medical Director/Assistant Medical Director may either contact the provider directly by telephone or may request clinical documentation to assist in the decision. A decision is to be rendered to the provider within three working days of the request or, in instances where more information is requested, within three working days of the receipt of requested information.

ENHANCED CARE MANAGEMENT

CBHA enrollees who are seriously and persistently mentally ill may be monitored closely as part of CBHA's commitment to quality, cost-effective delivery of behavioral health care for all enrollees in the health plan. CBHA has established an Enhanced Care Management program in order to provide follow up for individuals who meet certain clinical criteria. In the Enhanced Care Management process, the CBHA case Manager will follow up with the member and the provider to assure that the member is accessing needed services and making appropriate progress.

Individuals with a primary DSM (most recently-published edition) diagnosis and at least on of the following criteria may be selected to participate in this program:

• Demonstrated need for assistance in obtaining and coordinating treatment, rehabilitation and social services;
• More than one inpatient hospitalization in 6-months
• History of non-compliance with treatment programs
• Recent detox from a substance abuse program
• High utilization of outpatient benefits

The Clinical Care Manager works in conjunction with the network provider to identify resources and community support systems for long-term maintenance.