Chapter 26: Behavioral Health Services

EmblemHealth looks to its medical and behavioral health providers to collaborate in caring for our members with mental health or substance abuse issues. We strongly encourage our primary care providers (PCPs) to use screening tools to identify members who may need more specialized care and screening tools to identify the social drivers of and barriers to health. If you have a member in need of mental health or substance abuse care, Carelon Behavioral Health (formerly Beacon Health Options) administers our behavioral health services under two programs: 

EmblemHealth Behavioral Management Program (BMP)

For members of plans underwritten by EmblemHealth Plan, Inc., see the:

• 2024 Summary of Companies, Lines of Business, Networks & Benefit Plans
• 2023 Summary of Companies, Lines of Business, Networks & Benefit Plans

Emblem Behavioral Health Services Program (EBHSP)

For members of plans underwritten by HIP or EmblemHealth Insurance Company, and our Bridge Program, see the:

• 2024 Summary of Companies, Lines of Business, Networks & Benefit Plans
• 2023 Summary of Companies, Lines of Business, Networks & Benefit Plans

Although care for Medicaid and HARP members is coordinated through their Health Homes, covered behavioral health benefits are managed by Carelon Behavioral Health and accessed through their provider network. Look for the section dedicated to Medicaid and HARP members later in this chapter.

Providers must verify member eligibility and benefits prior to rendering non-emergency services.

Refer to the Carelon Behavioral Health Provider Handbook for full program requirements.

Under both programs, members access care through Carelon Behavioral Health's contracted providers. Carelon Behavioral Health manages all behavioral health covered services including utilization management and case management.

For EmblemHealth training presentations and other learning opportunities, see the Learning Online webpage.
 

Additional behavioral health resources are available on the Clinical Corner webpage.

It's important for primary care providers (PCPs) to screen their patients for depression and other behavioral health issues. We look to our PCPs to take mental health and substance abuse issues into consideration when developing treatment plans. Where possible, identify and coordinate care with your patient’s behavioral health providers.

To help you diagnose and refer members for further care, see the Behavioral Health Screening Tools in the online Provider Toolkit, as well as our Behavioral Health Screening Tools Pocket Reference.

You may also consult the Carelon Behavioral Health PCP Toolkit for additional resources.

Primary care providers (PCPs) are responsible for conducting applicable behavioral health screenings. PCPs can have members between the ages of 11 to 18 complete a Patient Health Questionnaire for Adolescents to help evaluate if an adolescent is suffering from depression, anxiety, or another emotional or mental health condition.

We reimburse PCPs for administering a mental health checkup during a well-child exam or a routine office visit in accordance with the Well-Child Visit Reimbursement Codes for Mental Health Screening. The codes must indicate a separately identifiable evaluation and management (E/M) service is performed.

PCPs may consult with Carelon Behavioral Health regarding appropriate medication management. PCPs may also refer higher-risk adolescents to a behavioral health practitioner. The New York State Office of Mental Health regulations define appropriate access to services and quality of care for children and adolescents treated in clinics licensed by the New York State Office of Mental Health. For more information on these and other guidelines, visit the New York State Office of Mental Health website.

• Use our online Find Care tool to find a mental health or substance abuse practitioner.
• Members may call 888-447-2526.
• Providers may call  800-397-1630

Children’s Health and Behavioral Health Services

EmblemHealth manages behavioral and physical health services for Medicaid-enrolled children and youth under 21 years of age.

Benefits include Children and Family Treatment and Support Services (CFTSS) and Home and Community Based Services (HCBS) designed to provide children/youth access to a vast array of supportive services.

Children/youth eligibility for HCBS is determined by an assessment that can be administered by a Health Home or a Children and Youth Evaluation Service (C-YES). For a comprehensive list of CFTSS and HCBS, please visit our website.

EmblemHealth collaborates with Carelon Behavioral Healths, Health Homes, C-YES, and HCBS providers to gather information to support the evaluation of:

• Enrollee level of care
• Adequacy of service plans
• Provider qualifications
• Enrollee health and safety
• Financial accountability and compliance

EmblemHealth uses aggregated data from its care management and claims systems to identify trends and opportunities for improving member care.

We use additional strategies to promote behavioral health-medical integration for children, including at-risk populations. These strategies include: 

• Provider access to rapid consultation from child and adolescent psychiatrists
• Provider access to education and training
• Provider access to referral and linkage support for child and adolescent patients

Adult Behavioral Health Services

EmblemHealth provides coverage of behavioral health services for Medicaid Managed Care (MMC) members 21 years of age or older who reside in New York City, and Nassau, Suffolk, and Westchester counties. The following behavioral health benefits are covered:

• Medically supervised outpatient withdrawal services
• Outpatient clinic and opioid treatment program services, which includes the administration of Medication Assisted Treatment (MAT)
• Outpatient clinic services
• Comprehensive psychiatric emergency program services
• Continuing day treatment
• Partial hospitalization
• Personalized recovery-oriented services
• Assertive community treatment
• Intensive and supportive case management
• Health home care coordination and management
• Inpatient hospital detoxification
• Inpatient medically supervised and managed inpatient detoxification
• Rehabilitation services for residential substance use disorder treatment
• Crisis services, including intensive crisis residential support
• Inpatient psychiatric services
• Psychological testing
• Electroconvulsive therapy (ECT)

Health and Recovery Plan (HARP)

EmblemHealth offers a Health and Recovery Plan (HARP) designed to meet the unique needs of MMC members aged 21 and older living with serious mental illness and/or substance use disorders. HARP services include all the behavioral services listed for MMC members in addition to the following Home and Community Based Services (HCBS) and Community Oriented Recovery and Empowerment (CORE) services: 

• Psychosocial Rehabilitation (PSR)
• Community Psychiatric Support and Treatment (CPST)
• Habilitation Services
• Family Support and Training
• Short-Term Crisis Respite
• Intensive Crisis Respite
• Education Support Services
• Peer Supports
• Pre-Vocational Services
• Transitional Employment
• Intensive Supported Employment (ISE)
• Ongoing Supported Employment
• Care Coordination

All HARP members and qualifying Medicaid members are offered Health Home care management services. Health Homes are responsible for coordinating all care between a member’s medical and behavioral health care providers. The Health Home will facilitate the development of a plan of care that encompasses both aspects of the member’s health.  If the member choses to not enroll in the Health Home program, access to HCBS and CORE services is still available through a referral from any Licensed Practitioner of the Healing Arts.

In some cases, non-routine behavioral health services require preauthorization. Members may be subject to a copay and/or deductible depending on their benefit plan.

Routine Outpatient Services – No Preauthorization

Preauthorization is not required for routine outpatient services. These services include initial consultation and individual, group, family, couple, and collateral treatment. Carelon Behavioral Health will reach out to practitioners when there are questions regarding the member’s clinical treatment.

Non-Routine Behavioral Health Services – Preauthorization or Notification Required

Preauthorization or notification is always required for the following services:

• Inpatient behavioral health treatment
• Autism treatment
• Outpatient ECT (electroconvulsive treatment)
• Partial hospitalization
• Intensive outpatient treatment and partial hospitalization for mental health only
• Neuropsychological testing
• Psychological testing

See Who to Contact for Preauthorization. Once Carelon Behavioral Health approves the service, you must notify your patient of the approval. You must notify Carelon Behavioral Health if you are unable to reach your patient (or their designee).

Carelon Behavioral Health administers the Case Management Program for all members. Members with the greatest risk of needing intensive behavioral health services, including inpatient care, are eligible for case management services. Members are identified through multiple sources, including provider referrals using the Mental Health number on the back of the member’s ID card.


Case managers contact enrolled members, devise a treatment care plan, and coordinate with treatment provider(s) to assist with medication adherence and treatment plan compliance. The program involves frequent telephonic counseling sessions with the case manager and face-to-face visits in the community, when possible, to keep the member out of the hospital.

Claims
For information on submitting claims, see the Directory Chapter’s Claims Contacts. See also, Carelon Behavioral Health Provider Handbook.

For electronic claims:
Carelon Behavioral Health encourages electronic claims submission through its secure ProviderConnect website, or through a clearinghouse. For assistance, contact a Carelon Behavioral Health Electronic Claims Specialist at 888-247-9311.

For paper claims:

• Outpatient professional services must be billed on a CMS-1500 form. Include the billing and rendering providers’ national provider identifier (NPI) and tax identification numbers (TIN). Billed lines are limited to 10 per claim form.
• Facility services must be billed using a UB-04 (CMS-1450) form with all applicable fields completed and all required elements/information included.

Claims Status
To check on a claim’s status, go to carelonbehavioralhealth.com or call 800-397-1630.

Medicare members: Submit to EmblemHealth. See Dispute Resolution Chapter for Medicare Plans.

All other members: Submit to Carelon Behavioral Health. See Carelon Behavioral Health Provider Handbook.

Providers are required to have appropriate Carelon Behavioral Health agreements, and complete Carelon Behavioral Health's credentialing process to care for EmblemHealth members. For information about contracting, call the Carelon Behavioral Health National Provider Line at 800-397-1630 from 8 a.m. to 8 p.m. 

Required Agreements:

BHP: Carelon Behavioral Health practitioner agreement (for EmblemHealth Plan, Inc. members)

EBHSP: Providers must have both:

• CHCS IPA agreement (for Health Insurance Plan of Greater New York (HIP) members)
• Carelon Behavioral Health practitioner agreement (for EmblemHealth Insurance Company members and Bridge Program members)