CurrentHealth NetPolicy N/A

Position Statement on Treatment of Highly Specialized Populations

Policy governing authorization and network handling for behavioral health treatment programs tailored to specialized employment groups (e.g., law enforcement, healthcare professionals) who require separate or specialized settings; affects plan behavioral health management and members in those groups.

Policy Summary

PayerHealth Net

PolicyPosition Statement on Treatment of Highly Specialized Populations

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 9, 2007

Next Review DateN/A

Key ActionBehavioral health will authorize care at specialized programs and will attempt to execute a single case agreement or treat the program as in-network for the member.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5+examples of specialized groups listed

2007-01-09original effective date

2020-06-04committee approval / last review

2020-06-08date updated in database

Coverage Criteria

Authorization for specialized-population programs

Covered when ALL of the following are met

Specialized program authorization: Member is part of a specialized employment group (examples include law enforcement officers, penal system guards, first responders, healthcare professionals, other impaired professionals) AND behavioral health recognizes the need for specialized treatment for that member

Behavioral health will authorize care at programs prepared to treat these populations and will attempt to arrange a single case agreement or treat the program as in-network regardless of SCA completion.

No explicit exclusions are listed in this policy.

Not applicable — the policy does not specify conditions under which services are considered not medically necessary.

Provider Actions and Authorization

Policy Summary

PayerHealth Net

PolicyPosition Statement on Treatment of Highly Specialized Populations

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 9, 2007

Next Review DateN/A

Key ActionBehavioral health will authorize care at specialized programs and will attempt to execute a single case agreement or treat the program as in-network for the member.

SourceLink

On This Page

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Prior Authorization

Authorization and single case agreement — Behavioral health will authorize care at programs prepared to treat special populations and will make efforts to execute a single case agreement (SCA) with the facility

Behavioral health will authorize care at programs prepared to treat special populations (for example, law enforcement officers, penal system guards, first responders, healthcare professionals, and other impaired professionals) for members of those groups who are willing to accept treatment. When a specialized program is needed that is not currently in the Plan network, behavioral health will make every effort to develop a single case agreement (SCA) with the facility and, if possible, bring that facility into the Plan network. Behavioral health will treat the program as in-network for the member whether the program completes an SCA, joins the network, or chooses to remain out-of-network. Behavioral health may add other specialized groups to this list as approved by the Behavioral Health Clinical Leadership Committee.

Affected populations: law enforcement officers, penal system guards, first responders, healthcare professionals, other impaired professionals
Authorization contingent on behavioral health identifying need for specialized program and making efforts to execute an SCA or network agreement
Program treated as in-network for the member whether or not SCA completed or facility joins network

Note

Network/SCA handling — When a specialized program is needed, behavioral health will attempt to develop a single case agreement (SCA) with the facility and, if possible, bring that facility into the Plan network.

When a specialized program is needed, behavioral health will attempt to develop a single case agreement (SCA) with the facility and, if possible, bring that facility into the Plan network. This effort applies whether the program serves the Plan's full population or only specialized groups. If the program remains out-of-network or does not complete an SCA, behavioral health will nevertheless treat it as in-network for the member in need of that specialized care.

Denial Risk

Authorization contingent on behavioral health action — No explicit denial triggers stated. However, authorization is contingent on behavioral health identifying need and making efforts to execute an SCA or otherwise secure appropriate treatment.

Authorization is contingent on behavioral health identifying the member's need for specialized treatment and taking action to secure an appropriate program (for example, pursuing an SCA or network placement). There are no explicit denial triggers stated in this policy; however, authorization depends on behavioral health's determination of need and its efforts to arrange treatment with a program prepared to treat the specialized population.

Definitions

Highly specialized populations — definition and scope

DefinitionMembers whose employment or licensure requires specialized treatment settings or programs (examples: law enforcement officers, penal system guards, first responders, healthcare professionals, other impaired professionals)

RationaleThese groups may be unable or unwilling to participate in local programs due to role conflicts, confidentiality, licensure concerns, or risk to job function

Initial listed groupsLaw enforcement officers; penal system guards; first responders; healthcare professionals; other impaired professionals

Policy actionBehavioral health will identify and provide specific and unique treatment management for these groups to achieve best possible outcomes

Network handlingBehavioral health will attempt to develop a single case agreement (SCA) or bring specialized programs into the Plan network; programs may be treated as in-network even if an SCA is not completed

OpenPayer

Position Statement on Treatment of Highly Specialized Populations

Coverage Criteria

Provider Actions and Authorization

Background

Definitions

Level of Care Criteria

Treatment Modalities