Provider Manual

Chapter 26: Behavioral Health Services

In this chapter, you'll find our policies and procedures for mental health and substance abuse services, including:

  • Prior approval procedures
  • Post-discharge protocols
  • Mental Health Parity Law
  • Health Homes

EmblemHealth has engaged Beacon Health Options to administer behavioral health services for most of its members under two programs. Members of plans underwritten by HIP or HIPIC and ASO plans administered by Vytra Health Plans Managed Systems (VHMS) have their behavioral health services administered by Beacon Health Options under the Emblem Behavioral Health Services Program (EBHSP). GHI-underwritten plan members by have their behavioral health services administered by Beacon Health Options under the EmblemHealth Behavioral Management Program (BMP).

 

For information on accreditation, prior approvals, claims and more, please see the Beacon Health Options Provider Manual: beaconhealthoptions.com/providers/emblemhealth.

 

It is very important for our physical health network practitioners to be aware of their patients’ mental health and substance use disorders. We ask our PCPs to screen their patients for depression and other potential issues and to take these diagnoses into consideration when developing treatment plans. Where possible, please identify and coordinate care with your patient’s behavioral health providers. Care for FIDA members will be coordinated in their IDTs and Medicaid and HARP members through their Health Homes.

Behavioral health services for members in plans underwritten by HIP or in ASO plans administered by VHMS are administered by Beacon Health Options under the Emblem Behavioral Health Services Program.

 

Provider Networks served by EBHSP include:

  • Enhanced Care Prime Network
  • NY Metro Network (Retired August 1, 2018)
  • Premium Network
  • Prime Network
  • Select Care Network
  • VIP Prime Network

 

Under EBHSP, Beacon Health Options administers covered inpatient, outpatient and ambulatory behavioral health services including provider network and care management services such as utilization management and case management. Beacon Health Options also manages credentialing, claims processing, claims payment and grievances and appeals (except for Medicare plans), as well as other provider service issues related to Behavioral health.

 

Members may call 1-888-447-2526 or use our online Find a Doctor tool to find a mental health or substance abuse practitioner.

 

Montefiore members can access behavioral health providers in the Montefiore network. They also may use the Beacon Health Options network if they choose. For providers who are not Montefiore network participants, claims for members who have the Montefiore logo on their ID card must be submitted to Beacon Health Options. Utilization management functions for behavioral health services for these members, including prior approvals, are performed by Montefiore. Please call 1-800-401-4822 for help finding a Montefiore network mental health or substance abuse practitioner.

 

Note: EmblemHealth administers disease management, including the Depression Disease Management program, for all members except for Medicare plans which will be administered by Beacon Health Options effective August 1, 2015. For more information on Serious and Persistent Mental Illness Disease Management Services, visit the Care Management Programs section of the Health Promotion and Disease Management chapter.

 

Health and Recovery Plan (HARP)

Our Health and Recovery Plan (HARP), Enhanced Care Plus, is designed to meet the unique needs of members living with serious mental illness and/or substance use disorder. For more information on HARP and other Medicaid services, please see the Medicaid section of the Provider Network and Member Benefit Plans chapter.

 

Medicaid Health Homes

All HARP members and qualifying Medicaid members will be assigned to Health Homes that will be responsible for coordinating all of their care. It is especially important for there to be coordinated 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.

 

A Health Home is a care management service model whereby all of an individual's caregivers communicate with one another so that all of a patient's needs are addressed in a comprehensive manner. This is done primarily through a "care manager" who oversees and provides access to all of the services an individual needs to assure that they receive everything necessary to stay healthy, out of the emergency room and out of the hospital. Health records are shared among providers so that services are not duplicated or neglected. Health Home services are provided through a network of organizations – providers, health plans and community-based organizations. When all the services are considered collectively they become a virtual "Health Home."

 

For information on MMC and HARP covered services, please see the Medicaid section of the Provider Network and Member Benefits Plans chapter.

 

Contracting with Beacon Health Options: Emblem Behavioral Health Services Program

To care for all members served by the EBHSP, providers are required to participate in both of the Beacon Health Options practitioner networks and must have a Beacon Health Options practitioner agreement and a CHCS IPA agreement (collectively referred to as "Beacon Health Options Agreements").

 

Providers who only have a CHCS IPA agreement will only be permitted to provide in-network care to Health Insurance Plan of New York (HIP) members.

 

Providers who only have a Beacon Health Options practitioner agreement will only be permitted to provide in-network care to HIPIC-underwritten members and members of ASO plans administered by VHMS.

 

For patients in an active course of treatment prior to January 1, 2012, please see Continuity of Care During Program Implementation.

Members of EPO and PPO plans underwritten by GHI have their behavioral health services administered by Beacon Health Options under the Behavioral Management Program (BMP).

Provider Networks served by BMP include:

  • CBP Network, National Network, Tristate Network
  • Network Access Network
  • Medicare Choice PPO Network

 

Under BMP, Beacon Health Options manages covered inpatient, outpatient and ambulatory behavioral health services, including provider network and care management services such as utilization management and case management. Provider claims should be submitted to EmblemHealth, except those for Medicare members; these claims should be submitted to Beacon Health Options. Appeals and grievances should be submitted to Beacon Health Options, except for those of Medicare members; these appeals and grievances should be submitted to EmblemHealth.

 

Contracting with Beacon Health Options: Emblem Behavioral Health Services Program

To care for GHI members served by the BMP, providers are only required to have a Beacon Health Options practitioner agreement.

 

For more information about contracting with Beacon Health Options, please call the Beacon Health Options National Provider Line at 1-800-397-1630 from 8 a.m. to 5 p.m. and ask to speak with the Credentialing department.

 

Providers must be contracted in the Beacon Health Options network(s) to provide covered behavioral health care to members served by BMP and EBHSP.

 

You and your patients are able to find EBHSP and BMP practitioners and facilities by going to our online Find a Doctor tool and entering the patient's ID number at the beginning of the search. Since some of our benefit plans use different provider networks, entering the patient's ID number will ensure that the search locates a provider that participates in the patient's benefit plan.

 

network(s) to provide covered behavioral health care to members served by BMP and EBHSP.

 

You and your patients are able to find EBHSP and BMP practitioners and facilities by going to our online Find a Doctor tool and entering the patient's ID number at the beginning of the search. Since some of our benefit plans use different provider networks, entering the patient's ID number will ensure that the search locates a provider that participates in the patient's benefit plan.

In some cases, coverage of behavioral health services to a member served by EBHSP or BMP requires a prior approval before the service can be rendered. Members may be subject to a copay and/or deductible depending on their benefit plan.

 

Routine Outpatient Services - No Prior Approval

Prior approval is not required for routine outpatient services. These services include initial consultation and individual, group, family, couple and collateral treatment. Beacon Health Options will, however, reach out to practitioners when there are questions regarding the member's clinical treatment.

 

Services Requiring Prior Approval

Prior approval is always required for the following services:

  • Inpatient behavioral health treatment
  • Ambulatory detoxification treatment
  • Outpatient ECT (electro-convulsive treatment)
  • Partial hospitalization
  • Intensive outpatient treatment
  • Neuropsychological testing
  • Psychological testing

 

How to Obtain Prior Approval

Program

Instructions

Emblem Behavioral Health Services Program
(HIP members)

Requests may be submitted via the Beacon Health Options Provider Connect website: https://www.beaconhealthoptions.com/providers/beacon or by calling Beacon Health Options at 1-888-447-2526.

(For members who have the Montefiore logo on the lower left corner of their ID card)
Montefiore members can access behavioral health providers in the Montefiore network. Requests may be submitted by calling 1-800-401-4822.

EmblemHealth Behavioral Management Program
(GHI members) 

Requests may be submitted via the Beacon Health Options Provider Connect website: https://www.beaconhealthoptions.com/providers/beacon or by calling Beacon Health Options at 1-800-692-2489.

 

Note: Once Beacon Health Options approves the service, you must notify your patient of the approval. You must notify Beacon Health Options if you are unable to reach your patient (or his or her designee).

 

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

Beacon Health Options encourages electronic claim submission through their secure ProviderConnect website in order to expedite claims processing and assist participating providers in submitting claims and other routine transactions. Electronic claim submission is also accepted through clearinghouses. When using the services of a Clearinghouse, providers must reference Beacon Health Options’ Payer ID, FHC &Affiliates, to ensure Beacon Health Options receives those claims. For more information, please contact a Beacon Health Options Electronic Claims Specialist at 1-888-247-9311.

 

If submitting on paper, outpatient professional services must be billed on a CMS-1500 form and include the billing and rendering providers’ NPI and Tax Identification Numbers. Please note: Billed lines are limited to 10 per claim form. Please send paper claims submissions to:

 

Beacon Health Options
PO Box 1850
Hicksville, NY 11802-1850

 

To check on the status of a claim, please go to beaconhealthoptions.com or call 1-800-235-3149

The Case Management Program is administered by Beacon Health Options for all members (except for those with the Montefiore logo on their ID card).

 

Patients who have the greatest risk of needing intensive behavioral health services including inpatient care are eligible for case management services. Patients are identified through multiple sources including provider referrals.

 

An enrolled patient is assigned a case manager who will contact them, devise a treatment care plan and will work with their treatment provider(s) to assist with medication adherence and treatment plan compliance. The Case Management Program involves frequent telephonic counseling sessions between the case manager and patient to aid the patient in staying out of the hospital.

 

To refer a patient to the Case Management Program, please call the Mental Health number on the back of the member's ID card.

Behavioral Health Screenings for Patients

The role of health care professionals has evolved to include discussing and addressing mental health and substance use disorders with patients. In fact, the relationships that patients have with their doctors and other health care professionals have proven to be one of the most important factors in ensuring individuals receive appropriate behavioral health care.

 

Recognizing the signs of a behavioral health condition is not always easy. We are providing you with the following behavioral health screening tools to help you diagnose and refer individuals for further care.

 

Measure

Tool

About the Tool

Scoring and Action Steps

Depression

PHQ-21

Depression Screen - 2 Questions

Score of 0-2 = Negative screen
Action: None
Score of 3+ = Positive screen
Action: Administer the PHQ-91.

PHQ-91

Depression Screen - 9 Questions

Score of 1-4 = Minimal depression 
Action: Watchful waiting; repeat PHQ-9 at follow-up visit. 
Score of 5-9 = Mild depression 
Action: Watchful waiting; repeat PHQ-9 at follow-up visit. Possible referral to behavioral health care professional for psychotherapy within 30 days of positive screen.
Score of 10-14 = Moderate depression 
Action: Develop treatment plan, consider pharmacotherapy and/or 
referral to behavioral health care professional for psychotherapy within 30 days of positive screen.
Score of 15-19 = Moderately severe depression
Action: Active treatment with pharmacotherapy and/or referral to behavioral health care professional for psychotherapy within 30 days of positive screen. 
Score of 20-27 = Severe depression 
Action: Immediate initiation of pharmacotherapy and, if severe impairment or poor response to therapy exists, expedite referral to behavioral health care professional for psychotherapy and/or collaborative management.
Positive score on Item 9.
Action: Immediate initiation of pharmacotherapy and, if severe impairment or poor response to therapy exists, expedite referral to behavioral health care professional for psychotherapy and/or collaborative management.

PHQ-9 - Modified for Teens2

Depression Screen - 9 Questions

Score of 1-4 = Minimal depression 
Action: Watchful waiting; repeat PHQ-9 at follow-up visit. 
Score of 5-9 = Mild depression 
Action: Watchful waiting; repeat PHQ-9 at follow-up visit. Possible referral to behavioral health care professional for psychotherapy within 30 days of positive screen.
Score of 10-14 = Moderate depression 
Action: Develop treatment plan, consider pharmacotherapy and/or 
referral to behavioral health care professional for psychotherapy within 30 days of positive screen.
Score of 15-19 = Moderately severe depression
Action: Active treatment with pharmacotherapy and/or referral to behavioral health care professional for psychotherapy within 30 days of positive screen. 
Score of 20-27 = Severe depression 
Action: Immediate initiation of pharmacotherapy and, if severe impairment or poor response to therapy exists, expedite referral to behavioral health care professional for psychotherapy and/or collaborative management.
Positive score on Item 9.
Action: Immediate initiation of pharmacotherapy and, if severe impairment or poor response to therapy exists, expedite referral to behavioral health care professional for psychotherapy and/or collaborative management.

Edinburgh Postnatal Depression Scale3

Depression Screen - 10 Questions

Score of 0-9 = Low probability of depression
Action: Watchful waiting; repeat Edinburgh Postnatal Depression Scale at follow-up visit.
Score of 10-30 = High probability of moderate to severe depression
Action: Develop treatment plan, possible active treatment with pharmacotherapy and/or referral to behavioral health care professional for psychotherapy within 30 days of positive screen.
If a patient scores a 1, 2, or 3 on question 10, please address suicidal thoughts immediately.
Action: Immediate initiation of pharmacotherapy and, if severe impairment or poor response to therapy exists, expedite referral to behavioral health care professional for psychotherapy and/or collaborative management.

Geriatric Depression Scale (GDS)4

Depression Screen - 15 Questions

Score of 1-4 = Minimal depression
Action: Watchful waiting; repeat GDS at follow-up visit.
Score of 5-15 = Mild to severe depression
Action: Immediate initiation of pharmacotherapy and, if severe impairment or poor response to therapy exists, expedite referral to behavioral health care professional for psychotherapy and/or collaborative management.

Anxiety

GAD-21

Anxiety Screen -
2 Questions

Score of 0-2 = Negative Screen 
Action: None 
Score of 3+ = Positive screen 
Action: Administer the GAD-7.1

GAD-71

Anxiety Screen -
7 Questions

Score of 1-4 = Minimal anxiety 
Action: Watchful waiting; repeat GAD-7 at follow-up visit. 
Score of 5-9 = Mild anxiety 
Action: Watchful waiting; repeat GAD-7 at follow-up visit. 
Score of 10-14 = Moderate anxiety 
Action: Further diagnostic assessment by PCP or behavioral health care professional. Consider pharmacotherapy and/or psychotherapy. 
Score of 15-21 = Severe anxiety 
Action: Immediate initiation of pharmacotherapy and, if severe impairment or poor response to therapy exists, expedite referral to behavioral health care professional for psychotherapy and/or collaborative management.

Substance 
Abuse/ Dependence

NIDA-
Quick Screen
5

Alcohol/Drug and Tobacco Screen -
4 Questions (Single Question Screener Included)

If respondent indicates "No" for all drugs in prescreen. 
Action:
 Reinforce abstinence.
If respondent indicates “Yes” to any of the drugs listed.
Action: Review current list of medications to ensure medications prescribed are not at risk for abuse. Provide brief counseling (5-15 minutes) to help the patient develop a plan to reduce drinking, identify high-risk situations, and learn coping strategies. Consider referral to behavioral health care professional within 60 days of positive screen.

AUDIT-C6

Alcohol Screen - 3 Questions

Score of 0-3 in Men / Score of 0-2 in Women = Minimal to moderate use. Low probability of abuse or dependence.
Action: Reinforce abstinence. Watchful waiting; repeat AUDIT-C at follow-up visit.
Score of 4-12 in Men / Score of 3-12 in Women=Moderate to severe use. High probability of abuse or dependence.
Action: Review current list of medications to ensure medications prescribed are not at risk for abuse. Provide brief counseling (5-15 minutes) to help the patient develop a plan to reduce drinking, identify high-risk situations, and learn coping strategies. Consider referral to behavioral health care professional within 60 days of positive screen.

Substance Use

AUDIT7

Alcohol Screen - 10 Questions

Score of 1-7 = Minimal to moderate use. Low probability of abuse or dependence.
Action: Reinforce abstinence. Watchful waiting; repeat AUDIT at follow-up visit.
Score of 8-15 = Moderate to severe use. Moderate probability of abuse or dependence.
Score of 16-19 = Moderate to severe use. Moderate to high probability of abuse or dependence.
Score of 20-40 = Severe use. High probability of abuse or dependence.
Action steps for scores of 8 or higher:
Review current list of medications to ensure medications prescribed are not at risk for abuse. Provide brief counseling (5-15 minutes) to help the patient develop a plan to reduce drinking, identify high-risk situations, and learn coping strategies. Consider referral to behavioral health care professional within 60 days of positive screen.

Suicidality

CSSRS - Clinical Screener8

Suicide Severity Screen, Clinical Practice Screener - Recent - 6 Questions

1 or more “Yes” responses are a positive screen. 
Action:
 Refer to behavioral health care professional to evaluate risk factors and determine appropriate treatment setting. 
A “Yes” response to question #4 or #5 in the past month or any behavior in question #6 is an indication of severe risk.
Action: Refer to behavioral health care professional to evaluate for hospitalization.

 

Our Physician Pocket Reference, a comprehensive booklet that incorporates all of these screening tools, is available for your use. We hope you find it useful in your practice.

 

Please also consult the Beacon Health Options PCP Toolkit for additional resources.

1Spitzer, R.; Williams, J. B.W.; Kroenke, K. and colleagues, with an educational grant from Pfizer. No permission required to reproduce, translate, display, or distribute. 2Johnson J.G., Harris E.S., Spitzer R.L., Williams, J.B.W.: The Patient Health Questionnaire for Adolescents: Validation of an instrument for the assessment of mental disorders among adolescent primary care patients. J Adolescent Health 30:196–204, 2002. 3Cox, J.L., Holden, J.M., and Sagovsky, R. 1987. Detection of postnatal depression: Development of the 10-item Edinburgh Postnatal Depression Scale. British Journal of Psychiatry150:782-786. and K. L. Wisner, B. L. Parry, C. M. Piontek, Postpartum Depression N Engl J Med vol. 347, No 3, July 18, 2002, 194-199. 4Yes average: The Use of Rating Depression Series in the Elderly, in Poon (ed.): Clinical Memory Assessment of Older Adults, American Psychological Association, 1986. 5National Institute on Drug Abuse; National Institutes of Health; U.S. Department of Health and Human Services. 6Bradley, K. A., Bush, K. R., Epler, A. J., et al (2003). Two brief alcohol-screening tests from the Alcohol Use Disorders Identification Test (AUDIT): Validation in a female Veterans Affairs patient population. Arch Intern Med. 163:821-9 and Bush, K., Kivlahan, D.R., McDonell, M.B., et al (1998). The AUDIT alcohol consumption questions (AUDIT-C): an effective brief screening test for problem drinking. Ambulatory Care Quality Improvement Project (ACQUIP). Arch Intern Med. 158:1789-95. 7Babor, T.F.; de la Fuente, J.R.; Saunders, J.; and Grant, M. AUDIT. The Alcohol Use Disorders Identification Test. Guidelines for use in primary health care. Geneva, Switzerland: World Health Organization, 1992. 8Developed by Drs. Posner, K.; Brent, D.; Lucas, C.; Gould, M.; Stanley, B.; Brown, G.; Fisher, P.; Zelazny, J.; Burke, A.; Oquendo, M.; Mann, J.

 

Additional Behavioral Health Screening Resources

Measures

Tool

About the Tool

Scoring and Action Steps

Depression

CES-D

Depression Screen - 20 Questions

See instructions for more information.

Depression

MFQ

Depression Screen - Several Versions

See instructions for more information.

Substance Use

ORT

Opioid Use Screen - 5 Questions

See instructions for more information.

Substance Use

CAGE-AID

Alcohol Screen - 4 Questions

See instructions for more information.

Substance Use

MSSI-SA

Alcohol/Drug Screen - 16 Questions

See instructions for more information.

Substance Use

NIAAA

Alcohol Screen - 3 Questions

See instructions for more information.

Substance Use

SOAPP

Opioid Screen - 14 Questions

See instructions for more information.

Suicidality

C-SSRS - Pediatric Lifetime /Recent

Suicide Severity Screen, Initial Visit - 5 Questions

See instructions for more information.

Suicidality

C-SSRS - Pediatric Since Last Visit

Suicide Severity Screen, Since Last Visit - 5 Questions

See instructions for more information.

Suicidality

C-SSRS - Risk Assessment Page

Protective and Risk Factors Checklist for Suicidality

See instructions for more information.

For Adolescents, or members that are between the ages of 11 to 18, emotional or mental health can affect how prepared they will be for school, their ability to connect with friends and family, and their ability to bounce back when faced with life's setbacks. Supporting an adolescent’s emotional development and well-being is just as important as their physical health. Sometimes it is hard to know if an adolescent’s emotional development is on track.

 

EmblemHealth engages practitioners with a wide range of services, supports and information to help our practitioners determine their member’s emotional health needs.

 

The Mental Health Checkup

Primary care practitioners (PCPs) are responsible for conducting applicable behavioral health screenings. We ask our PCPs to have our adolescent members complete a Patient Health Questionnaire for Adolescents while they are in the waiting or exam room. The questionnaire can help evaluate if an adolescent is suffering from depression, anxiety or other condition. When a mental illness is identified early, the adolescent has the best chance to lead a healthy life and reach their full potential.

 

Why Primary Care Practitioners

PCPs are in a unique position to help detect mental health conditions. According to the US Surgeon General, 21 percent of our nation's youth suffers from a diagnosable mental disorder that causes impairment, but 80 percent are not identified and do not receive help. Further, about two million teenagers are affected by depression; however, most of them go undiagnosed and untreated.

 

EmblemHealth looks to its PCPs to be on guard for potential behavioral health diagnosis. Mental health screening is an effective way to identify an at-risk adolescent and its recommended by the US Preventive Services Task Force the Institute of Medicine, American Academy of Pediatrics, American Academy of Family Physicians and National Association of pediatric Nurse Practitioners.

 

PCPs may consult with Beacon Health Options, who manages the Behavioral Health benefit, 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, please visit the New York State Office of Mental Health website: https://www.omh.ny.gov/omhweb/clinic_restructuring/appendix2.html.

Note to all Providers: Although offered in context of FIDA, the downloadable provider trainings are a useful resource for you and your staff regarding cultural competency, identifying and supporting patients with behavioral health issues and accommodating the disabled and the elderly. The Behavioral Health Training explains how to identify and support individuals with various diagnoses. For more EmblemHealth training presentations and other learning opportunities, please see the Learn Online.

 

Please click on the links below for additional resources that will assist providers in identifying and supporting patients with Behavioral Health needs:

On October 3, 2008 Congress enacted the Health Parity and Addiction Equity Act of 2008 (MHPAEA). The MHPAEA is a federal law that applies to large group, Medicare and Child Health Plus members whose group enrolled in a plan on or after October 3, 2009.

 

Under the MHPAEA, the expanded coverage for behavioral health services enacted by the New York State legislature under Timothy's Law was further enhanced to include substance abuse treatment and non-biologically based mental health treatment.

 

As a result of the MHPAEA, there is no day or visit limitation for members covered by the act who have a behavioral health benefit and meet medical necessity criteria. Prior approval requirements continue to apply to these services.

 

As of November 1, 2009 there are no limits to behavioral health services for Child Health Plus members.