Name of Manual - Blue Cross and Blue Shield of Minnesota

Coding Policies and Guidelines (Behavioral Health)
Pre-certification and
Concurrent Review for
Inpatient/Residential
Mental Health and
Substance use
Disorder Services –
(continued)
Groups that Carve Out
Behavioral Health
Benefits
11-56
Provider shall obtain pre-certification by calling Blue Cross at
(651) 662 5270 or toll free at 1-800-528-0934. Blue Cross will use
criteria set forth in the Level of Care Utilization System (LOCUS)
and Child and Adolescent Services Intensity Instrument (CASII)
for mental health or the Dimensions criteria for substance use
disorders in conducting a medical necessity review for the
admission.
Failure to provide evidence of medical necessity may result in
claim denials as provider liability.
Concurrent Review Requirements
Providers have a contractual obligation as noted in Chapter 4 of
the online Blue Cross Provider Policy and Procedure Manual to
adhere to care management programs. At the time of precertification
a date will be established to conduct concurrent
review.
Concurrent review will include verification of medical necessity
based on criteria set forth in the LOCUS and CASII for mental
health or the Dimensions criteria for substance use disorders.
Failure to provide evidence of medical necessity may result in
claim denials as provider liability.
Some self-insured contract with another carrier to manage their
behavioral health benefits. This means that their behavioral health
claims should be filed to the designated third party behavioral
health carrier for processing. This carrier’s information should be
obtained from the patient.
E/M services (codes 99201-99215) and medication management
services (codes 90862 or M0064) billed with a behavioral health
diagnosis for carve out group members should be billed to Blue
Cross as long as the practitioner is a non-behavioral health
practitioner or a multi-specialty clinic. If one of these services is
denied, Blue Cross should be contacted for it to be reprocessed.
These services will be paid at the behavioral health benefit but will
not accumulate towards patients’ behavioral health benefit
maximums. Any other behavioral health treatment for carve out
group members that is billed to Blue Cross will be denied.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12