CurrentSharp-Health-PlanPolicy HS-BH-02

MATERNAL MENTAL HEALTH CASE MANAGEMENT PROGRAM

Defines Sharp Health Plan's maternal mental health case management program for prenatal, postpartum, and interpregnancy members in California, including referral, outreach, and program procedures for providers and members.

Policy Summary

PayerSharp-Health-Plan

PolicyMATERNAL MENTAL HEALTH CASE MANAGEMENT PROGRAM

Policy CodePolicy HS-BH-02

Change TypeRevised to comply with SB 1207

Effective DateJul 1, 2023

Next Review Date

Key ActionRefer members with positive maternal mental health screens to Sharp Health Plan case management by completing the Case Management Referral form or calling 1-858-499-8300.

SourceLink

POLICY UPDATE CHANGES

Policy revised to comply with SB 1207 to include quality measures for ensuring compliance.

1 business daynotification to referral source of receipt

5 business daysCM outreach to member after referral

3 call attemptsphone attempts before mailing Unable to Contact letter

Jul 2023SB 1207 implementation date

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Coverage Criteria — Maternal Mental Health Case Management

Maternal Mental Health Case Management Eligibility and Workflow

Covered when ALL of the following are met

Enrollment/Referral: Member is identified as having a maternal mental health condition or is referred/self-refers to the Plan

Referrals accepted from providers, members, hospital staff, or other sources

Outreach timeline: Plan RN or LCSW Case Manager notifies referral source within 1 business day and attempts telephone outreach to member within 5 business days1 business day; 5 business days

If member not reached after three attempts, an Unable to Contact letter is mailed

Member response: If member agrees, engage in complex case management; if member declines, assist with behavioral health appointments and provide community resources

Complex case management includes additional assessment, identification of social determinants of health, goal/barrier setting, and ongoing monthly follow-up

No explicit exclusions listed in the policy. The Sharp Health Plan Maternal Mental Health Case Management Program documentation does not identify any specific services, diagnoses, provider types, or member groups that are excluded from the program; referrals are accepted from any source and program guidelines are available to providers on request.

None specified. The policy does not list any services or situations that are considered not medically necessary for the maternal mental health case management program.

Provider Actions — Screening, Referral, Documentation

Note

Referral pathway

No prior authorization is required to refer members to Sharp Health Plan's network behavioral health providers or to the Plan's maternal mental health case management program. Referrals will be accepted from any source, including providers, members, hospital staff, or facility utilization reviewers/case managers.

Case management referrals may be made by completing the Case Management Referral form on the Sharp Health Plan website or by calling 1-858-499-8300.

Prior Authorization

Provider action highlight

If a patient has a positive maternal mental health screening, the provider should take action to ensure timely connection to services: direct the mother to a Sharp Health Plan network behavioral health provider or refer to the Plan's case management department. A referral for behavioral health is not required to access behavioral health services.

Positive screening → direct referral to network behavioral health provider (no behavioral health referral form required).
Positive screening → refer to case management (Case Management Referral form or phone).

Definitions

inv-09: Maternal Mental Health Condition — definition and examples

DefinitionA mental health condition that occurs during pregnancy, the postpartum period, or interpregnancy and includes, but is not limited to, postpartum depression.

Typical timingOccurs during pregnancy, the postpartum period, or interpregnancy.

ExamplesPostpartum depression and other perinatal mood and anxiety disorders.

inv-10: Health and Safety Code 1367.625 — statutory requirement summary

Statutory dutyLicensed health care practitioners who provide prenatal or postpartum care must ensure the mother is offered screening or is appropriately screened for maternal mental health conditions.

Plan obligationsHealth plans must develop mental health programs designed to promote quality and cost-effective outcomes and provide program guidelines to relevant medical providers.

Background

Maternal mental health conditions occur during pregnancy, the postpartum period, or interpregnancy and include conditions such as postpartum depression. Early identification through screening and timely linkage to behavioral health services or the Plan’s case management supports improved quality and outcomes for mothers by assisting with needs like understanding benefits, making appointments, and connecting to community resources. The Plan’s program is designed to meet California regulatory requirements (Health & Safety Code 1367.625) and to provide outreach and materials to providers to ensure regulatory compliance.

Level of Care — Outpatient Case Management

Case Management and Referral to Behavioral Health

If member agrees to CM: Engage in complex case management including assessment, social needs identification, goal setting, and monthly follow-up

Complex case management process described in separate desk top procedure

If member declines CM: Provide referral assistance to behavioral health providers and other community resources such as support groups, financial, legal

Referral to network behavioral health provider not required; providers may refer via Case Management Referral form or phone

Visit Limits and Follow-up

inv-13: complex case management — monthly follow-up specified

Follow-up frequencyOngoing monthly follow-up as part of complex case management to track and evaluate progress until goals are met or the member disengages.

ComponentsIncludes additional assessment, identification of social determinants of health needs, and identification of goals and barriers.

Entry triggerMonthly follow-up occurs if the member agrees to engage in the complex case management program after outreach.