Behavioral health facilities

Pre-authorization is required for the services listed below. For select CPT codes, including transcranial magnetic stimulation services, Availity's electronic authorization tool automatically connects to MCG Health's website where specific clinical criteria can be documented for your patient. If all criteria are met, an approval will be received on the Auth/Referral Dashboard.

• Inpatient: Psychiatric, eating disorder or ASAM 4.0 detoxification
  • Authorization requests should be submitted as soon as possible and are accepted within 3 business days of admission.
  • Timely concurrent review will be required if additional days are requested after an initial authorization is issued. Concurrent review records are due on the last covered date of an authorization. Failure to follow concurrent review requirements may result in an administrative denial, claim non-payment and provider and facility write-off. Members may not be balance billed.
• Residential levels of care (LOC)
  • Includes chemical dependency (ASAM 3.7and ASAM 3.5) residential, mental health residential and eating disorder residential requests.
    • Authorization requests must be received within 3 business days of admission.
    • For services provided in the state of Washington:
      • Initial notification of admission of ASAM 3.7 or ASAM 3.7 LOC can be submitted prior to sending an authorization request if clinical records are not available at the time of admission.
• Partial hospitalization & intensive outpatient treatment
  • Includes mental health, eating disorder and chemical dependency (ASAM 2.5, ASAM 2.1)
    • Request for authorization is required within 7 calendar days of start date.

• Transcranial magnetic stimulation (TMS) & applied behavior analysis (ABA)

  • Request for authorization is required within 7 calendar days of start date.
  • ABA services require authorization for all members regardless of age.

For details, view our pre-authorization lists, including concurrent review requirements.

We require forms for initial, concurrent and step-down requests; and discharge confirmation. Initial requests can be submitted through Availity Essentials. See the Forms & policies tab for authorization submission forms. Requests can be submitted through the following:

• Email: FAXBHRepository@asuris.com
• Fax: 1 (888) 496-1540

• Submit initial request forms through Availity Essentials

  • Sign in to the Availity Essentials
  • Click: Patient Registration>Authorizations & Referrals>Authorizations
  • Complete the authorization request and attach our initial request form

• You should only initiate a pre-authorization request when clinical information is available for our clinicians to review.
• Include contact information for the person who can answer questions or provide additional information, if needed. This allows us to complete our review promptly.

• If you are asking for a concurrent review past the last covered day, submit the request 24 hours prior to the expiration of the last covered day. This will give us time to process the review timely and provide opportunity to coordinate an appeal, if not approved.

There may be exceptions to obtaining pre-authorization. The seven situations listed below may apply as part of our Extenuating Circumstances Policy Criteria (under Pre-authorization exception):

• Natural disaster prevented the provider or facility from securing a pre-authorization or providing hospital admission notification.
• A participating provider or facility is unable to anticipate the need for a pre-authorization before or while performing a service or surgery.
• A surgery that requires pre-authorization occurs in an urgent/emergent situation. Services are subject to review post-service for medical necessity.
• The member is unable to communicate (e.g., unconscious) medical insurance coverage. Neither family nor collateral support present can provide coverage information.
• An enrollee is discharged from a facility and insufficient time exists for institutional or home health care services to receive approval prior to delivery of the service.
• There is compelling evidence the provider attempted to obtain pre-authorization. The evidence must show the provider followed our policy and that the required information was entered correctly by the provider office into the appropriate system.

• The member presented with an incorrect member ID card or member number, or indicated they were self-pay and that no coverage was in place at the time of treatment, or the participating provider or facility is unable to identify from which carrier or its designated or contracted representative to request a pre-authorization.

Learn how to:

• Notify us about an extenuating circumstance (under Pre-authorization exception) prior to claim submission.
• Appeal a claim that has been administratively denied in the Appeals for Providers section of our Administrative Manual.

If you have received a denial of a pre-authorization request, please consult the denial letter for any appeal process specific to the member's plan.

All post-service provider appeals must be submitted using the Appeals application on Availity Essentials.

We offer case management free of charge to members who need individualized assistance navigating their behavioral health care. Our case managers are licensed behavioral health professionals who can:

• Be a direct point of contact with the health plan
• Coordinate care for members with more complex needs
• Assist members in locating mental health chemical dependency providers

• Provide ongoing support, coaching and assistance to members in conjunction with the member's treatment professionals

Facilities and other treatment providers may request a case manager by completing a Care Management Referral Request Form.

A case manager will reach out within three business days of receiving the request.

• Authorization to Disclose Protected Health Information - Fillable form
• Authorization to Disclose Protected Health Information - Spanish

• Asuris Medical Policy Manual—transcranial magnetic stimulation (TMS), applied behavior analysis (ABA) and services for Medicare Advantage members
• Asuris Reimbursement Policy Manual
• The American Society of Addiction Medicine (ASAM) guide (PDF)
• Level of Care Utilization System (LOCUS) guide (PDF)
• Child and Adolescent Level of Care/Service Intensity Utilization System (CALOCUS-CASII) guide (PDF)
• Early Childhood Service Intensity Instrument (ECSII) guide (PDF)

To request a full copy of our behavioral health clinical review criteria, call our Provider Contact Center at 1 (888) 349-6558.

The Healthcare Effectiveness Data and Information Set (HEDIS®) behavioral health measure Follow-Up After Hospitalization for Mental Illness (FUH) is a key quality measure that ensures members transition safely from an acute hospital setting back to their home environments. Our goal is to help members receive the post-discharge care they need.

Timely follow-up (within seven days) and effective care coordination help improve outcomes. Care coordination is a vital aspect of good treatment planning. We encourage communication among a member’s providers and the health plan.

These best practices meet the measure’s standard and have proven to be effective in achieving positive outcomes:

• Follow-up can occur any time between days one and seven; the day of discharge is day zero, and appointments on the day of discharge do not count toward compliance with the measure.
• Follow-up must occur with a behavioral health provider.

• Follow-up visits may be held in office, via telehealth or through billable visits by phone.

Provider types

• Psychiatrist
• Licensed clinical social worker (LCSW)
• Licensed marriage and family therapist (LMFT)
• Licensed professional counselor (LPC)
• Psychiatric nurse

• Psychologist

Programs

• Intensive outpatient (IOP)

• Partial hospitalization (PHP)

The following provider types and programs are not included in the FUH measure:

• PCP
• Drug and alcohol counselor
• Non-licensed clinicians

• Support groups

By working with us, the member and the member’s family or support system, we can collectively ensure members have successful discharge plans and are able to function to their highest ability when they leave the hospital setting.

Your facility should:

• Begin follow-up planning at the time of inpatient admission and involve and educate the patient’s family about the follow-up plan
• Encourage your patients to sign an Authorization to Disclose Protected Health Information form
  • Most behavioral health information can be shared among treating providers—even those in different organizations—without a release of information (ROI) for the purposes of coordinating care. Requesting an ROI before coordinating care can delay appropriate care and can lead to poor outcomes. Exception: ROIs are required for coordinating with substance use disorder (SUD) providers or facilities.
  • Medicare Advantage members
  • All other Asuris members
  • Spanish
• Discuss the follow-up plan with your patient and the importance of follow-up visits
• Schedule follow-up appointments, including one within seven days of discharge
• Ensure accurate post-discharge contact and follow-up information

• Call your patient to remind them of the follow-up appointment

Our care management team will:

• Determine a follow-up plan during the inpatient review process
• Assist in securing follow-up appointments, including locating new providers if needed
• Offer support by contacting members after their discharge to discuss the follow-up plan
• Help our members understand the importance of follow-up appointments

• Encourage timely outpatient follow-up with a licensed behavioral health provider

Read about the FUH measure in our Quality Measures Guide.