Family Road Map Guide

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Manage INFORMATION
Two Key Words That
Open Doors
Health insurance policies
cover behavioral health
treatments that are medically
necessary, a very
important term that means
the services are required to
treat your child’s symptoms.
When your treatment team’s
providers want the BHO to
approve services that aren’t
usually covered by the plan,
including more days or
sessions of treatment, they
must show that the services
are medically necessary.
Sometimes you will have to
get experts at the BHO to
review your child’s case. You
may also have to go higher
up the chain of command at
the insurance company or
file an appeal.
How “Managed Care” Works
When a doctor or other clinician evaluates your child or youth and recommends a
treatment plan, you, as the parent, must agree to this plan in advance. If your child
receives benefits (services that are paid for), the insurance company will also get
involved before treatment starts. Providers hired by the company must agree ahead
of time that the insurance plan’s guidelines (rules) do cover those services. This
process is called a utilization review, and the providers who do this task (often
nurses and social workers) are called utilization reviewers or case managers.
Sometimes another provider, such as a child psychiatrist, will review your child’s
case file if there are questions about what your child needs.
You or your child’s behavioral health provider can request this added review
when trying to change a decision about your child’s coverage (services paid for
under the plan).
If the recommended treatment fits the plan’s guidelines, the reviewer will
authorize those services (give advance permission for the services and agree to
pay for them). In the case of some benefits, such as psychotherapy, the insurance
company will often authorize a certain number of sessions. Your child’s therapist
will have to submit another treatment plan to get more sessions approved.
Sometimes this process takes place with a phone call, but in other cases,
written records have to be sent. Either way, number codes are used on the paperwork.
The codes stand for certain kinds of services and reasons that the services
are needed. Sometimes a claim can be denied because somebody accidentally
used the wrong code or made a mistake entering the information into the computer.
As a parent, you may need to get on the phone with staff in the behavioral health
provider’s office, or with someone at the insurance company to fix such errors.
A Note about Number Codes: If a claim has been denied, always call
customer service first to check if the right number code was used! This can save a
lot of time and trouble!
The insurance company that pays for services may do this review on its own,
or it may use another MCO. If so, you may need to call one phone number to ask
questions about benefits or solve problems, and a different number for questions
about billing. When problems occur, you may have to get in touch with that company
using the customer service number on the ID card or in the member’s handbook
(printed or online). You may also need to look for the mental health and substance
abuse (MH/SA) number.
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