Medical Management

Behavioral Health Management

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

  • Inpatient and concurrent certification
  • Prior authorization request review
  • Post-service review

The Behavioral Health Management program does not require triage or the prior authorization process prior to a customer 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 prior authorization determination of all services referred to inpatient 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.
  • Inpatient 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 prior authorization approval decisions are given to the practitioners and customers, 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 prior authorization approval decisions are given to the practitioners and customers, 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.
  • Prior authorization approval decision letters for select services are sent to the customer, the PCP (if applicable), the practitioner to whom the customer 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, customer, and PCP, if applicable, by telephone or letter. Denial letters are sent to the practitioner, customer, 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 customer representation and time frames for deciding appeals/grievances.
  • A description of the expedited appeal/grievance process for urgent prior authorization 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 inpatient 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 customer’s care across the continuum of health care services.

  • Inpatient concurrent review is done via telephone by Medical Management staff.
  • All data and relevant information is obtained, including, but not limited to, medical records and communications with practitioners or other consultants.
  • Relevant information is reviewed using utilization management criteria as described in resources/tools section.
  • Inpatient 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 customer 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, prior authorization 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 customer 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.