Behavioral health services coverage and prior authorization
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Defines Health New England coverage, prior authorization requirements, and submission instructions for behavioral health and substance use disorder services for Commercial and Medicare Advantage members (HNE Be Healthy managed via MBHP).
No material clinical or coverage changes in this revision.
Coverage Criteria
General coverage stance
Covered when medically necessary or as allowed by the member's plan or state law.
Determinations are based on the most current edition of the InterQual Level of Care Criteria or HNE Clinical Review Criteria; BH Department conducts concurrent reviews for ongoing SUD services as permitted by law.
The following services are not covered under the behavioral health/substance use disorder benefit: educational services or testing (except services covered under the benefit for Early Intervention Services); services for problems of school performance; faith-based counseling; social work for non-mental health care; Christian Science practitioner and sanitarium stays; and services required by a third party or court-ordered residential/custodial services (including residential treatment programs and halfway houses).
No additional coverage statements are specified in the inventory for this section.
Key Definitions
Level of Care Criteria
Inpatient
Admission, concurrent review, and notification requirements for inpatient behavioral health services.
Concurrent review is conducted for ongoing hospitalization to ensure continued medical necessity, as permitted by state law.
Partial Hospitalization / IOP / Day Treatment
Prior authorization requirements for higher‑level outpatient programs and listed treatment modalities.
Prior authorization is not required for treatment of Substance Use Disorder by DPH/BSAS‑licensed providers for Partial Hospitalization Program and Intensive Outpatient Treatment.
Treatment Modalities
Behavioral health services requiring prior authorization
Prior authorization applies to these behavioral health services (provider must specify procedure codes and requested units/days/visits on the prior authorization form).
Providers must supply the Procedure Description and Code and specify Units/Days/Visits requested on the Standardized Prior Authorization Request Form.
Coding
| Procedure Description and Code | Providers must supply the specific procedure code(s) on the prior authorization form |
Provider Actions & Prior Authorization
Prior Authorization Required
The following behavioral health (BH) services require prior authorization from Health New England Health Services. Use the Standardized Prior Authorization Request Form when submitting requests.
- Providers must submit the Standardized Prior Authorization Request Form at least seven days prior to the scheduled service date when possible.
- Standardized Prior Authorization Forms are available at http://healthnewengland.org/forms.
- Send requests to: Health New England, Attention: Health Services, One Monarch Place, Suite 1500, Springfield, MA 01144. Fax: (413) 233-2700.
Required Documentation for Prior Authorization
Complete the Standardized Prior Authorization Request Form fully and attach all pertinent clinical documentation so Health Services can make an informed determination within standard decision timeframes.
- Attach a statement of medical necessity and relevant office notes, lab results, imaging reports, and consultation reports.
- Include specific clinical information describing the condition, prior treatments, response to treatment, and rationale for the requested service.
- If information is missing, Health Services may request additional information which will delay review; incomplete submissions may lead to denial.
Provider Action & Submission Instructions
The requesting provider is responsible for submitting the form and ensuring required fields and attachments are included. Health Services will send written confirmation of the decision to the requesting physician, the provider rendering the service, the member, and the member's PCP. If a Medical Necessity denial is issued, the referring provider will also receive a phone call.
- Provider information to include: requesting provider name, phone, fax; servicing provider name, phone, fax; servicing facility name (if applicable); contact person name, phone, fax.
- Member information to include: member name, date of birth, HNE ID number, diagnosis, procedure description and code, units/days/visits requested, service start and end date.
- For assistance, contact HNE Provider Relations at (800) 842-4464 ext. 5000, or Health Services at (413) 787-4000 ext. 5027, or (800) 842-4464 ext. 5027.
Incomplete Documentation May Delay or Trigger Denial
If required information is not submitted with the initial request, Health Services may request additional information and the review will be delayed. Health Services may deny the request if documentation remains incomplete or does not support medical necessity.
- Ensure all required fields on the Standardized Prior Authorization Request Form are completed and all supporting documentation is attached to avoid delays or denials.
- Once all necessary information is received, Health Services will make a coverage determination and notify appropriate parties in writing.
Units, Days, and Visits
Background
Health New England covers medically necessary behavioral health and substance use disorder services across inpatient and outpatient settings for applicable members. Medical necessity determinations are based on the most current edition of the InterQual Level of Care Criteria or HNE's Clinical Review Criteria, and the BH Department conducts concurrent reviews of ongoing hospitalization and SUD services where permitted by law. Prior authorization and notification requirements apply to specific higher-level outpatient programs and listed treatment modalities as detailed elsewhere in this policy.
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