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Behavioral Health Services for Children Covered by Medicaid Managed Care Effective July 1

We would like to provide you with information related to the second phase of the New York State Children’s Health and Behavioral Health Medicaid System Transformation, which will occur July 1, 2019.

Excellus BlueCross BlueShield (“Health Plan”) will implement several additional behavioral health outpatient services and one new service under Children and Family Treatment and Support Services (CFTSS) for eligible children/youth under the age of 21 with Medicaid managed care (MMC) coverage (i.e., HMOBlue Option, Blue Choice Option and Premier Option). Some of these services require preauthorization or prior notification before services are rendered, and we have included those details on the following pages.

For additional information related to the expansion of Children’s Behavioral Health Services, please visit the New York State Department of Health website, www.health.ny.gov/health_care/medicaid/redesign/behavioral_health/children/web-info_child_mst.htm

Please share this important information with all practice locations or corporate offices, and with anyone in your practice who should be aware. If you have questions about this notice, contact your Behavioral Health Provider Relations representative.

Thank you for your partnership and collaboration as we continue our mission to provide access to quality, affordable health coverage to our members.

Services Available July 1, 2019, for MMC-Eligible Children/Youth Under Age 21

Children’s Behavioral Health Carve-In Services (PREAUTHORIZATION REQUIRED)

The following services will be carved into MMC effective July 1, 2019, and preauthorization for these services will be required for dates of service on or after October 1, 2019*:

  • Assertive Community Treatment**
  • Continuing Day Treatment**
  • Partial Hospitalization Program
  • Personalized Recovery-Oriented Services**

*Preauthorization may be requested as early as September 1, 2019, for dates of service on or after October 1, 2019.
** Member must be at least 18 years of age to receive coverage for this service.

Please refer to our website, https://provider.athg.excellusbcbs.com/authorizations/medical, for complete details related to the Health Plan’s preauthorization guidelines. The preauthorization section of our website will be updated no later than July 1, 2019.

Behavioral Health Carve-In Services (NO PREAUTHORIZATION REQUIRED)

The following services will be carved into MMC effective July 1, 2019, with no preauthorization required.

  • Comprehensive Psychiatric Emergency Program (CPEP) (including extended observation bed)
  • OASAS Outpatient Rehabilitation Services
  • Office of Alcoholism and Substance Abuse Services (OASAS) Outpatient Services
  • Opioid Treatment Program (OTP)

Children & Family Treatment & Support Services (PROVIDER NOTIFICATION REQUIRED)

The following CFTSS will be carved into MMC effective July 1, 2019. Preauthorization is not required for CFTSS; however, you are required to notify us upon initiation of services. Please contact us at 1-844-694-6411 to provide notification upon initiation of the following CFTSS.

Family Peer Support Services (FPSS) are an array of formal and informal services and supports provided to families raising a child to the age of 21 who is experiencing social, emotional, developmental and/or behavioral challenges in their home, school, placement, and/or community. The purpose of this service is to support the parents/family members and enhance their skills, so that they can support and promote the child’s ability to live successfully in his or her community.

We have included a listing of Current Procedural Terminology (CPT®) codes for CFTSS services on the last page of this notice. Please refer to the NYS Children’s Health and Behavioral Health Billing and Coding Manual and Transitional Billing Supplement for additional information: https://www.health.ny.gov/health_care/medicaid/redesign/behavioral_health/children/billing.htm.

The Health Plan will begin concurrent utilization review on January 1, 2020, which is 180 days from the date that FPSS is carved into MMC. Please note that concurrent review can be requested as early as December 1, 2019 for a January 1, 2020 effective date.

After a child’s initial three visits, the Health Plan will review the treatment plan and the three most recent progress notes, including the provider assessment, to evaluate medical necessity for authorization prior to the child receiving further services. The treatment plan should include clinical and/or functional information that the Health Plan needs from the treating provider to evaluate medical necessity for each service in the applicable Health Plan benefit package. A completed CFTSS Continuing Authorization Request Form will also be required. A copy of the form is included with this mailing.

If the Health Plan determines that continued services are medically necessary, the authorization period following the initial three visits must be inclusive of at least 30 service visits. The Health Plan will review services at reasonable intervals as determined by the Health Plan and consistent with the child’s treatment plan and/or the Health Plan’s plan of care.

Please remember that failure to provide notification or to comply with your provider or our member contract requirements, or utilization management policies and procedures, may result in claim denial or reduction in payment.

CFTSS CPT Codes with Modifiers

 
 
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