Currentharvard pilgrim health carePolicy N/A

Behavioral Health Care Authorization and Notification

Defines Harvard Pilgrim Health Care's management and prior authorization/notification requirements for behavioral health and substance use disorder (SUD) services, including crisis/emergency care, alternative programs (e.g., PHP), and specific outpatient services that require authorization; notes state-specific exceptions (Massachusetts) and operational contact pathways.

Policy Summary

Payerharvard pilgrim health care

PolicyBehavioral Health Care Authorization and Notification

Policy CodePolicy N/A

Change TypeRevisions/clarifications (historical)

Effective Date

Next Review Date

Key ActionAdmitting hospitals/facilities must notify Harvard Pilgrim within 72 hours for Massachusetts facilities or within two (2) business days for facilities in all other states.

SourceLink

POLICY UPDATE CHANGES

08/15/24 updated web address for UnitedHealthcare and removed phone number

09/01/23 updated for behavioral health insourcing effective on 11/01/23

09/15/22 added new Section, Maine Requirements for Management of Behavioral Health Benefits for Members Aged 21 Years or (incomplete title)

07/10/20 changed UBH to Optum and substance abuse to substance use disorder (SUD) throughout; clarified extended outpatient

01/09/19 added online resources information and clarified authorization and referral requirements; added information for Massachusetts plans only

5Example services requiring prior authorization listed

72h / 2bdAdmission notification timeframe (MA / other states)

14ATS/CSS first 14-day notification grace period (MA POS/PPO)

Policy summary

Harvard Pilgrim Health Care manages credentialing and re-credentialing of behavioral health and SUD providers; utilization management (including prior authorization) of behavioral health and SUD benefits; behavioral health and SUD provider network development and management; administration of behavioral health and SUD benefits including member services; and claims processing. Prior authorization processes reference separate medical necessity guidelines and the general Prior Authorization Policy; some outpatient and alternative programs (e.g., PHP) require prior authorization and are reviewed concurrently for ongoing medical necessity and discharge planning. Crisis and emergency behavioral health/SUD assessments do not require PCP referral or prior authorization, and post-stabilization services after an emergent inpatient behavioral health/SUD admission do not require prior authorization.

Key Metadata

PayerHarvard Pilgrim Health Care

PolicyBehavioral Health Care Authorization and Notification

Policy NumberN/A

Effective Date

Last Review2024-08-15

Next Review

StatusCURRENT

Key ActionDefines prior authorization and notification requirements for behavioral health and SUD services, including crisis/emergency assessments (no prior auth/referral), prior authorization for alternative programs and specified outpatient services, and state-specific (MA) exceptions for ATS/CSS.

Coverage & authorization criteria

Crisis Assessment

Covered without prior authorization or PCP referral when a behavioral health crisis is present:

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title": "Crisis Assessment"

ref": "b1_0" } ,{

ref": "b1_1",

citations": [

Operational actions & requirements for providers

Note

Urgent/emergent acute behavioral health admission notification

Admitting hospitals/facilities must notify Harvard Pilgrim of urgent/emergent acute behavioral health admissions within the required timeframes based on facility location.

Massachusetts facilities: within 72 hours
Facilities in all other states: within two (2) business days

Prior Authorization

Prior authorization required for alternative programs and specified outpatient services

Obtain prior authorization before admitting members to alternative programs (for example, Partial Hospitalization Program) and for certain outpatient behavioral health services. Follow the applicable medical necessity guidelines and prior authorization submission instructions, or call the Provider Service Center for assistance.

State-specific exceptions (Massachusetts)

For Massachusetts POS or PPO plans, prior authorization is not required for ATS or CSS from either a plan or non-plan provider. ATS/CSS services provided beyond the first 14 days may be subject to concurrent review under the member's plan. Providers should notify the Behavioral Access Center within 48 hours of an admission for ATS/CSS; coverage will not be denied for the first 14 days for failure to notify. For SUD treatment services other than ATS/CSS, prior authorization is not required when services are provided by a provider certified or licensed by the Massachusetts Department of Public Health.

Definitions

Crisis assessmentA pre-admission evaluation for an intensive behavioral, emotional, substance use, or psychiatric situation which, if left untreated, could result in an emergency; neither PCP referral nor prior authorization is required for a crisis assessment; after evaluation contact Harvard Pilgrim for assistance with admissions and coordination of care.

ATS/CSSAssessment and stabilization services / Community stabilization services; under MA POS or PPO plans prior authorization is not required for ATS or CSS from plan or non-plan providers, providers should notify the Behavioral Access Center within 48 hours of an ATS/CSS admission, and coverage will not be denied for the first 14 days for failure to notify; services beyond 14 days may be subject to concurrent review.

Coding

No codes listedmixed

No codes listed

Document revision history

01/09/19revised

Added online resources information and clarified authorization and referral requirements; added information for Massachusetts plans only

07/10/20clarified

Changed UBH to Optum and 'substance abuse' to 'substance use disorder (SUD)' throughout; clarified extended outpatient

09/15/22revised

Added new Section, Maine Requirements for Management of Behavioral Health Benefits for Members Aged 21 Years or (incomplete title)

Policy Summary

Payerharvard pilgrim health care

PolicyBehavioral Health Care Authorization and Notification

Policy CodePolicy N/A

Change TypeRevisions/clarifications (historical)

Effective Date

Next Review Date

Key ActionAdmitting hospitals/facilities must notify Harvard Pilgrim within 72 hours for Massachusetts facilities or within two (2) business days for facilities in all other states.

SourceLink

On This Page

title": "Emergency Care",

intro": "Emergency behavioral health/SUD services and notification requirements:",

title": "Alternative to Hospital Programs",

intro": "Authorization requirements for alternatives to inpatient hospitalization:",

title": "Prior Authorization through the Behavioral Health Department",

intro": "Outpatient and other services that require prior authorization through the behavioral health department:",

title": "Massachusetts Plans Only - ATS/CSS and SUD",

intro": "State-specific (Massachusetts) prior authorization exceptions and notification requirements:",

Transcranial Magnetic Stimulation (rTMS)

Psychological and Neuropsychological Testing

Applied Behavioral Analysis (ABA)

Non-urgent/non-emergent out-of-network services (for plans without out-of-network coverage)

Some Behavioral Health for Children & Adolescents services (e.g., In-Home Therapy Services, In-Home Behavioral Services)

Note

Behavioral Access Center notification for ATS/CSS (MA POS/PPO)

For Massachusetts ATS/CSS admissions under POS or PPO plans, providers should notify the Behavioral Access Center within 48 hours of admission. Coverage will not be denied for the first 14 days for failure to notify (the first 14 days are protected from denial).

First 14-day period: coverage will not be denied for failure to notify

Documentation Required

Post-evaluation coordination

After completing a crisis (pre-admission) evaluation, contact Harvard Pilgrim Health Care for assistance with admissions to alternate levels of care and for coordination of behavioral health care.

09/01/23revised

Updated for behavioral health insourcing effective on 11/01/23

08/15/24revised

Updated web address for UnitedHealthcare and removed phone number