Behavioral Health Program Clinical Requirements
This document lists clinical program requirements for a range of behavioral health treatment programs and services reimbursable by Blue Cross Blue Shield of Michigan and Blue Care Network; it applies to commercial and Medicare Advantage lines noted. It is intended for providers seeking authorization and coverage guidance for behavioral health services.
No material clinical or coverage changes in this revision.
Coverage Criteria and Program Applicability
Program applicability and high-level coverage stance
Programs listed with applicability indicators for mental health and/or substance use disorders; coverage depends on program and disorder as indicated.
Detailed medical necessity criteria and admission/continued stay/discharge criteria are in the program-specific requirement documents linked on the Behavioral Health webpage.
The table of program applicability indicates which behavioral health programs apply to mental health and/or substance use disorders. Use the table to determine applicability for each program: for example, opioid treatment programs (OTP) are shown as applicable to substance use disorders but not to mental health, and feeding/eating disorder PHP/IOP and residential psychiatric treatment are shown as applicable to mental health but not to substance use. When a program is not listed as applicable for a disorder type, the program-specific clinical requirements do not apply to that disorder as indicated in the table.
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