Currentharvard pilgrim health carePolicy N/A

Behavioral Health Care Authorization and Notification

Defines Harvard Pilgrim Health Care's authorization, notification, and utilization management requirements for behavioral health and substance use disorder services, and explains when prior authorization or notification is required for providers and facilities.

Policy Summary

Payerharvard pilgrim health care

PolicyBehavioral Health Care Authorization and Notification

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateAug 15, 2024

Key ActionObtain prior authorization before admitting members to alternative programs (e.g., Partial Hospitalization Program) and for specified outpatient behavioral health services such as rTMS, psychological/neuropsych testing, and ABA.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

72 hoursMA urgent/emergent notification

2 business daysNon-MA urgent/emergent notification

48 hoursNotify Behavioral Access Center (MA ATS/CSS)

14 daysATS/CSS first coverage period

Coverage and Authorization Rules

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Authorization and Coverage Rules

Coverage and authorization rules summarized below

Crisis and Emergency Care: Emergency/crisis assessments and emergency behavioral health/SUD services necessary to screen and stabilize members are covered and do not require prior authorization or PCP referral; facilities must notify Harvard Pilgrim within required timeframes after admission.

Notification timeframes: MA facilities within 72 hours; other states within 2 business days.

Alternative to Hospital Programs: Prior authorization is required before admission to alternative programs for psychiatric/SUD treatment such as Partial Hospitalization Program; stays are reviewed concurrently for ongoing medical necessity and discharge planning.

Specified Outpatient Prior Authorization: Prior authorization is required for certain outpatient behavioral health services including rTMS, psychological and neuropsychological testing, ABA, some in-home child/adolescent services, and non-urgent out-of-network services for plans without out-of-network coverage.

Providers should refer to applicable medical necessity guidelines for criteria and submission instructions.

Massachusetts-specific ATS/CSS: For Massachusetts POS/PPO plans, ATS/CSS from plan or non-plan providers does not require prior authorization for the first 14 days; providers should notify the Behavioral Access Center within 48 hours of admission; services beyond 14 days may be subject to concurrent review.14 days

Coverage will not be denied for failure to notify for the first 14 days.

This policy does not apply to members enrolled in the Choice or Choice Plus products offered through Passport Connect. For those members, providers must follow UnitedHealthcare policies and procedures available at www.uhcprovider.com and should not rely on the authorization or notification rules in this Harvard Pilgrim policy for those products.

Services provided beyond initial coverage periods may be subject to additional review. Specifically, for Massachusetts POS or PPO plans, ATS/CSS services delivered beyond the first 14 days may be reviewed concurrently and could be denied if not authorized or not found medically necessary under the member's plan. Providers should be aware that the first 14 days are protected from denial for failure to notify, but ongoing stays beyond that period require active review for continuing medical necessity.

Provider Authorization & Notification Actions

Prior Authorization

Prior Authorization Required for Alternative Programs

Prior authorization is required before admission to alternative to hospital programs (e.g., Partial Hospitalization Program). Alternative program stays are reviewed concurrently to evaluate ongoing medical necessity and to support timely discharge planning.

Partial Hospitalization Program (PHP)
Stays reviewed via concurrent review for ongoing medical necessity

Prior Authorization

Prior Authorization Required for Specified Outpatient Services

Prior authorization is required for certain outpatient behavioral health services. To request authorization, treating providers should follow the applicable medical necessity guidelines for the service and the Prior Authorization Policy for submission details. For HMO members needing non-urgent/non-emergent out-of-network services (when the plan does not cover out-of-network care), prior authorization from Harvard Pilgrim is required. Providers may call the Provider Service Center at 800-708-4414 for assistance.

Transcranial Magnetic Stimulation (rTMS)
Psychological and Neuropsychological Testing
Applied Behavioral Analysis (ABA)
Some Child & Adolescent services (e.g., In-Home Therapy Services, In-Home Behavioral Services)
Non-urgent/non-emergent out-of-network services for plans without out-of-network coverage

Note

General Prior Authorization Submission Instructions

For general prior authorization submission instructions (what to submit, how to submit, and required documentation), refer to the Prior Authorization Policy. The treating provider must follow the medical necessity guidelines for the specific service when preparing the authorization request.

See Prior Authorization Policy for submission methods and required documentation
Follow the applicable medical necessity guideline for the requested service

Prior Authorization

ATS/CSS (MA POS/PPO) Notification & Concurrent Review Expectations

Massachusetts POS/PPO ATS and CSS: prior authorization is not required for the first 14 days of ATS/CSS services from plan or non-plan providers. Providers must notify the Behavioral Access Center within 48 hours of an ATS/CSS admission. Services beyond the first 14 days may be subject to concurrent review under the member's plan.

No prior authorization required for ATS/CSS for first 14 days under POS/PPO (plan or non-plan provider)
Notify Behavioral Access Center within 48 hours of admission
Services beyond 14 days may be subject to concurrent review

Background and Rationale

Behavioral health crises encompass acute behavioral, emotional, substance use, or psychiatric situations that, if untreated, can escalate to medical emergencies. Emergency behavioral health and SUD services that are medically necessary to screen and stabilize members are covered and do not require prior authorization or a PCP referral; however, facilities must notify Harvard Pilgrim within the required timeframes after an urgent or emergent admission.

Utilization management balances timely access to emergency stabilization with appropriate oversight of ongoing, non-emergent care. For alternative-to-hospital programs (for example, Partial Hospitalization Program) and certain outpatient modalities, prior authorization is required before admission so that clinical appropriateness and discharge planning can be assessed. In Massachusetts, specific rules apply to ATS/CSS admissions: providers should notify the Behavioral Access Center within 48 hours of admission, and ATS/CSS from plan or non-plan providers does not require prior authorization for the first 14 days, but services extending beyond that period are subject to concurrent review.

Level-of-Care Decision Criteria

Inpatient / Alternative Programs / Outpatient

Crisis/ED admission: No prior authorization or PCP referral required for crisis assessment or emergency behavioral health/SUD admissions; facilities must notify Harvard Pilgrim within required timeframes.

MA: within 72 hours; other states: within 2 business days.

Alternative program concurrent review: Alternative program stays (e.g., PHP, ATS/CSS beyond initial period) are reviewed concurrently to evaluate ongoing medical necessity and discharge planning.

Visit Limits and Time-Based Rules

inv-13: ATS/CSS (Massachusetts POS/PPO)

Scope (MA POS/PPO)Prior authorization is not required for ATS or CSS from plan or non-plan providers under POS or PPO plans in Massachusetts.

Notification timingProviders should notify the Behavioral Access Center within 48 hours of an ATS/CSS admission.

First 14 daysCoverage will not be denied for the first 14 days of ATS/CSS for failure to notify.

Beyond 14 daysATS/CSS services provided beyond the first 14-day period may be subject to concurrent review under the member's plan.

SUD services noteFor SUD treatment services other than ATS/CSS, prior authorization is not required when provided by a provider certified or licensed by the Massachusetts Department of Public Health.

Policy Summary

Payerharvard pilgrim health care

PolicyBehavioral Health Care Authorization and Notification

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateAug 15, 2024

SourceLink

On This Page

OpenPayer

Behavioral Health Care Authorization and Notification

Coverage and Authorization Rules

Provider Authorization & Notification Actions

Background and Rationale

Key Definitions

Level-of-Care Decision Criteria

Applied Behavioral Analysis (ABA) Criteria

Specific Treatment Modalities

Visit Limits and Time-Based Rules