Medical Management

Behavioral Health Management

Behavioral Health Management program provides a mechanism to optimize use of the member’s health care benefits while providing high quality integrated health care to members with mental and/or substance abuse disorders. Services include, but are not limited to:

  • In-patient and concurrent certification
  • Pre-service request review
  • Post-service review
  • Case management

The Behavioral Health Management program does not require triage or the pre-service authorization process prior to a member contacting or making an appointment with a behavioral health practitioner. It is the practitioner’s responsibility to provide a treatment plan to Arise Health Plan for certain services.

The Behavioral Health Management program requires pre-service authorization determination of all services referred to in-patient facilities (including transitional and intensive outpatient rehabilitation), and non-participating practitioners or providers. These services may be reviewed for medical necessity, potential redirection to an appropriate Arise Health Plan practitioner and/or coordination of care/services.

  • Requests may be submitted by facsimile, telephone, or by mail.
  • All data and relevant information is obtained, including but not limited to medical records, communications with practitioner or other consultants.
  • Relevant information is reviewed using utilization management criteria as described in resources/tools section.
  • In-patient facility care, for example, observation, acute, and rehabilitation is reviewed prior to or within 24 business hours of admission, then concurrently according to accepted criteria and guidelines.
  • Determinations for non-urgent pre-service approval decisions are given to the practitioners and members, via oral, written, or electronic notification, within 15 calendar days of the request. Determinations for non-certifications (denials) in this category (non-urgent) are given within 15 calendar days of the request by written or electronic notification.
  • Determinations for urgent pre-service approval decisions are given to the practitioners and members, via oral, written, or electronic notification, within 72 hours of the request. Determinations for non-certification (denials) in this category (urgent) are given within 72 hours of the request via oral, written, or electronic notification.
  • Pre-service approval decision letters for select services are sent to the member, the PCP (if applicable), the practitioner to whom the member is being referred, and the facility, if appropriate.
  • All potential denials, for inpatient and ambulatory care, based on medical necessity, are reviewed by the Medical Director and a determination is made by him, or in conjunction with consultation of the Associate Director of Behavioral Health.

Denials are communicated to the practitioner, member, and PCP if applicable, by telephone or letter. Denial letters are sent to the practitioner, member, and PCP if applicable.

All written denial determination notification include:

  • The specific reason for the denial.
  • A reference to benefit provision, guideline, protocol, or other similar criterion on which the denial decision is based.
  • An offer to provide a copy of the actual benefit provision, guideline, protocol, or other similar criterion on which the denial decision was based, upon request.
  • A description of appeal/grievance rights, including the right to submit written comments, documentations, or other information relevant to the appeal/grievance.
  • An explanation of the appeal/grievance process, including the right to member representation and timeframes for deciding appeals/grievances.
  • A description of the expedited appeal/grievance process for urgent pre-service or urgent concurrent denial.
  • Notice of the Independent Review Process, if applicable.

Concurrent review decisions are reviews for the extension of previously approved ongoing care. Examples are, the review of in-patient care as it is occurring or ongoing ambulatory care. Concurrent review provides the opportunity to evaluate the ongoing medical necessity of care being provided, and supports the health care provider in coordinating a member’s care across the continuum of health care services.

  • In-patient concurrent review is done telephonically by Medical Management staff.
  • All data and relevant information is obtained, including but not limited to medical records, communications with practitioner or other consultants.
  • Relevant information is reviewed using utilization management criteria as described in resources/tools section.
  • In-patient concurrent review is continuous for the duration of the inpatient stay.
  • Urgent concurrent review decisions are made, and the practitioner notified, within 24 hours of receipt of the request. Approval decisions are determined by Medical Management staff and given to practitioners via oral, electronic, or written notification by facility case managers or discharge planner. Denial decisions are given orally or electronically and in writing to practitioner, facility, and member by Medical Management staff.
  • Concurrent review may include staffing with health care professional and/or home visits with home health care agencies.
  • Requests to extend a course of treatment previously approved that does not meet the definition of urgent care will be handled as a new request, for example, pre-service or post-service and the appropriate time frames followed.
  • All potential denial decisions based on medical necessity, related to concurrent review, are reviewed by the Medical Director and a determination made by him, or in conjunction with consultation of the Associate Director of Behavioral Health.

Post-service decisions are determinations of medical necessity and/or appropriate level of care when the care has already been received, for example, retrospective review. Notification of post-service decision denial determinations is given electronically or in written form to the practitioner and member within 30 calendar days of the request. For example, a claim received for out-of-area care that Arise Health Plan was never notified.

The Medical Director reviews all potential post-service denial decisions based on medical necessity, or appropriate level of care, and a determination is made by him, or his designee.

Members may be selected for Behavioral Health Case Management based on criteria that address various demographics, including but not limited to: age, psycho-social and economic status, support systems, diagnoses, complexity of treatment plan.

Cases may be identified through utilization reports, health promotion activities, claim activity reports, complicated in-patient admissions and practitioner, provider or member pre-service authorization. Case Management is conducted in collaboration with the physician, supports the physician/member relationship, and promotes adherence to an established treatment plan. Members are notified of their selection for case management.