Provider Manual

Chapter 26: Behavioral Health Services

This chapter includes information about EmblemHealth’s policies and procedures for mental health and substance abuse services. Beacon Health Options administers our behavioral health services under two programs:
 

EmblemHealth Behavioral Management Program (BMP)

  • Members of plans underwritten by GHI
     

EmblemHealth Behavioral Health Services Program (EBHSP)

  • Members of plans underwritten by HIP or HIPIC 
     

Care for Medicaid and HARP members is coordinated through their Health Homes.

BMP serves members in plans that use these provider networks:

  • 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. This includes provider network and care management services such as utilization management and case management.
 

Appeals and grievances should be submitted to Beacon Health Options, except those of Medicare members; these appeals and grievances should be submitted to EmblemHealth.
 

Submit claims to Beacon for members with a K-ID. Prior to transition to our new claims systems, continue to submit claims to EmblemHealth."
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Members may call 1-888-447-2526 or use our online Find a Doctor tool to find a mental health or substance abuse practitioner.
 

Provider Contracting for BMP

Providers are required to have a Beacon Health Options practitioner agreement to care for GHI members served by the BMP. For more information about contracting with Beacon Health Options, call the Beacon Health Options National Provider Line at 1-800-397-1630 from 8 a.m. to 8 p.m. 

EBHSP serves members in plans that use these provider networks:

  • Enhanced Care Prime 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 GHI and Medicare plans). Refer to the Beacon Health Options Provider Handbook for more information.
 

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

Provider Contracting for EBHSP

To care for members served by the EBHSP, providers are required to participate in both of 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 may only provide in-network care to Health Insurance Plan of Greater New York (HIP) members. Providers who only have a Beacon Health Options practitioner agreement may only provide in-network care to HIPIC-underwritten members.

Montefiore Network Participants

Montefiore members can access behavioral health providers in the Montefiore network and Beacon Health Options network. Utilization management functions for behavioral health services for these members, including prior approvals, are performed by Montefiore. For help finding a Montefiore network mental health or substance abuse practitioner, call 1-800-401-4822.
 

For providers who are not Montefiore network participants, claims for members with the Montefiore logo on their ID card must be submitted to Beacon Health Options. 

Children’s Health and Behavioral Health Services

EmblemHealth manages the delivery of expanded behavioral and physical health services for Medicaid-enrolled children and youth under 21 years of age. This includes medically fragile children, children with behavioral health diagnosis(es), and children in foster care with developmental disabilities. Benefits include Child 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 habilitative 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 Children's Family Treatment and Support Services provided under HCBS, please visit this page on our website.

EmblemHealth collaborates with Beacon Health Options, 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
  • 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 inpatient detoxification
  • Rehabilitation services for residential substance use disorder treatment
  • Inpatient psychiatric services

Health and Recovery Plan (HARP)

EmblemHealth offers a Health and Recovery Plan (HARP) designed to meet the unique needs of MMC members 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 HCBS:

  • 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 assigned to Health Homes, which are responsible for coordinating all care. It is 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.

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

For information on How to Obtain Prior Approval, see the Directory chapter. 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.

For information on submitting claims, see the Claims Contacts section of the Directory chapter.

Beacon Health Options encourages electronic claims submission through its secure ProviderConnect website, or through a clearinghouse. This will expedite claims processing and assist participating providers in submitting claims and other routine transactions. For more information, contact a Beacon Health Options Electronic Claims Specialist at 1-888-247-9311.

If submitting a claim on paper, outpatient professional services must be billed on a CMS-1500 form and include the billing and rendering providers’ national provider identifier (NPI) and tax identification numbers (TIN). Billed lines are limited to 10 per claim form.

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

EmblemHealth administers disease management, including the Depression Disease Management program, for all members except for Medicare plans that are administered by Beacon Health Options. For more information on Behavioral Health Disease Management Services, visit the Health Promotion and Care Management chapter of the Provider Manual.

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

Case managers will contact enrolled members, devise a treatment care plan, and coordinate with 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 member to aid in staying out of the hospital.

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

It's important for primary care physicians (PCPs) to screen their patients for depression and other potential behavioral health issues, and to take these diagnoses 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 Physician Pocket Reference.

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

 

Primary care practitioners (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.

Providers are reimbursed 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 Beacon Health Options 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.

Refer to the Behavioral Health Services section of our online Provider Toolkit for additional resources.

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