CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Medical Coverage Policy Mental Illness and Substance Use Disorders Mandate

Administrative policy documenting coverage requirements under Rhode Island mandate (27-38.2) and Federal Mental Health Parity Act for commercial products; describes coverage parity, medical necessity expectations, notification of admission, and applicability to Medicare Advantage and commercial plans.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyMedical Coverage Policy Mental Illness and Substance Use Disorders Mandate

Policy CodePolicy N/A

Change Typeclarified

Effective DateJan 1, 2022

Next Review Date

Key ActionProviders must furnish medical records or other necessary data upon request to substantiate initial or continued medical necessity and appropriateness of treatment.

SourceLink

POLICY UPDATE CHANGES

Policy documents mental illness coverage under Rhode Island state mandate and notes parity with the Federal Mental Health Parity Act.

Commercial productsApplies to

Medicare AdvantageAlso covered (not subject to state mandate)

48 hoursAdmission/Discharge notification timeframe

Coverage Summary

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This is an administrative policy documenting Rhode Island statutory requirements (RIGL 27-38.2) and Federal Mental Health Parity Act obligations for coverage of mental health and substance use disorder treatment. It applies to Commercial products (self-funded groups may vary) and notes that Medicare Advantage plans also cover these services but are not subject to the Rhode Island state mandate. Key parity requirements include parity of financial requirements, quantitative treatment limitations (QTLs), and non-quantitative treatment limitations (NQTLs) (NQTLs must be applied no more stringently to behavioral health than to medical/surgical benefits). The policy requires reliance upon the ASAM criteria when developing coverage for levels of care for substance use disorder treatment and specifies parity-consistent cost-sharing for behavioral health counseling and medication maintenance visits with primary care office visits.

Coverage for treatment of mental illness and substance use disorders

Covered when ALL of the following are met:

The policy applies to Commercial Products only (may vary by group contract; self-funded groups may not follow state mandates).

Treatment of mental illness and substance use disorder is a covered benefit.

Medication-assisted treatment or medication-assisted maintenance services of substance use disorders (including methadone, buprenorphine, naltrexone, or other clinically appropriate medications) are included within the appropriate classification based on site of service.

Parity - financial/QTLs: Coverage must be provided under the same terms and conditions as coverage for other illnesses and diseases (parity of financial requirements and quantitative treatment limitations).

NQTL parity: Non-quantitative treatment limitations (NQTLs) may not be applied more stringently to behavioral health than to medical/surgical benefits; processes and evidentiary standards used must be comparable and no more stringent.

ASAM reliance: Health insurers must rely upon American Society of Addiction Medicine (ASAM) criteria when developing coverage for levels of care for substance use disorder treatment.

Cost-sharing parity: Cost-sharing for behavioral health counseling visits and medication maintenance visits must be consistent with cost-sharing for primary care office visits, regardless of provider license if within scope of practice and credentialing/contracting.

Medical-Necessity & Appropriateness

Medical necessity and appropriateness

Determinations of medically necessary and appropriate treatment must be made in a manner consistent with determinations for other diseases or injuries covered under the health insurance policy.

Upon request, providers must furnish medical records or other necessary data to substantiate that initial or continued treatment is medically necessary and appropriate.

If provider cannot establish medical necessity/appropriateness for a period or type of care, neither insurer nor patient is obligated to reimburse for that period or type of care, except if patient was informed and agreed in writing to continue at own expense.

Documentation Required

Medical records upon request

Providers must furnish medical records or other necessary data upon request to substantiate that initial or continued treatment is medically necessary and appropriate. Furnish requested records promptly to support claims and utilization review.

Denial Risk

Denial for failure to establish medical necessity

Claims may be denied for periods or types of care for which the provider cannot establish medical necessity or appropriateness. The insurer and patient are not obligated to reimburse for care lacking documented necessity unless the patient was informed and agreed in writing to continue treatment at their own expense.

Admission Notification

Notification of admission requirement

Notification of Admission is required for both in-network and out-of-network behavioral health and substance use services.

Providers must notify BCBSRI Behavioral Health Utilization Management within 48 hours of admission and within 48 hours of discharge.48 hours

Contact BCBSRI Behavioral Health Utilization Management at 1-800-274-2958.

Prior Authorization

Notification of admission within 48 hours

Providers must notify BCBSRI Behavioral Health Utilization Management within 48 hours of both admission and discharge for in-network and out-of-network behavioral health and substance use services to ensure correct claims processing.

1-800-274-2958

Background & Definitions

Rhode Island law (RIGL 27-38.2) and the Federal Mental Health Parity Act require that coverage for mental health and substance use disorders be provided under the same terms and conditions as coverage for other illnesses. Parity applies to financial requirements, quantitative treatment limitations, and non-quantitative treatment limitations (which may not be applied more stringently to behavioral health). Medication-assisted treatment (including methadone, buprenorphine, naltrexone, or other clinically appropriate medications) is included and payors must rely on the American Society of Addiction Medicine (ASAM) criteria when developing levels-of-care coverage.

Medication-assisted treatment: Medication-assisted treatment or maintenance services including methadone, buprenorphine, naltrexone, or other clinically appropriate medications for substance use disorders.

Provider Actions & Responsibilities

Providers must furnish medical records or other necessary data upon request to substantiate initial or continued medical necessity and appropriateness of treatment. Providers are required to notify BCBSRI Behavioral Health Utilization Management within 48 hours of admission and within 48 hours of discharge for both in-network and out-of-network behavioral health and substance use services (contact 1-800-274-2958). Claims or reimbursement may be denied for periods or types of care for which the provider cannot establish medical necessity/appropriateness, unless the patient was informed and agreed in writing to continue treatment at their own expense.

Documentation Required

Provide records on request

Prior Authorization

Notify UM within 48 hours of admission/discharge

Notify BCBSRI Behavioral Health Utilization Management within 48 hours of admission and within 48 hours of discharge for both in-network and out-of-network behavioral health and substance use services.

1-800-274-2958

Denial Risk

Claims denial risk

Claims may be denied for periods or types of care for which the provider cannot establish that treatment was medically necessary or appropriate. Exception: if the patient was informed and agreed in writing to continue at their own expense, reimbursement may not be denied for that period.

Revision History

2022-01-01effective

Policy effective date: 01/01/2022 (Medical Coverage Policy Mental Illness and Substance Use Disorders Mandate).

2023-10-04last_reviewLatest

Policy last updated/reviewed on 10/04/2023.

clarified

Administrative policy; no clinical criteria specified. Policy documents mental illness coverage under Rhode Island state mandate and notes parity with the Federal Mental Health Parity Act.