|
July 2019
We’re using updated utilization management criteria for behavioral health
On Aug. 1, 2019, Medicare Plus BlueSM PPO, Blue Cross Blue Shield of Michigan’s Medicare Advantage plan, and Blue Care Network’s commercial and Medicare Advantage plans (BCN HMOSM and BCN AdvantageSM) will begin using the 2019 InterQual® criteria for behavioral health utilization management determinations.
We previously communicated about this in a web-DENIS message and a news item at ereferrals.bcbsm.com.
In addition, certain types of determinations will be based on modifications to InterQual criteria or on local rules or medical policies, as shown in the table below:
| Line of business |
Modified 2019 InterQual criteria for: |
Local rules or medical policies for: |
| Medicare Plus Blue PPO |
- Substance use disorders: partial hospital program and intensive outpatient program
|
None |
| BCN HMO (commercial) and BCN Advantage |
- Substance use disorders: partial hospital program and intensive outpatient program
- Residential mental health treatment (adult/geriatric and child/adolescent)
|
- Autism spectrum disorder/applied behavior analysis (BCN HMO only)
- Neurofeedback for attention deficit disorder/attention deficit hyperactivity disorder
- Transcranial magnetic stimulation
- Telemedicine (telepsychiatry/teletherapy)
|
Note: Determinations on Blue Cross PPO (commercial) behavioral health services are handled by New Directions, an independent company that provides behavioral health services for some Blue Cross members.
Links to the updated versions of the modified criteria (local rules) and medical policies are available, as applicable, on the Blue Cross Behavioral Health page and the BCN Behavioral Health page at ereferrals.bcbsm.com. For information on non-behavioral health InterQual criteria, see the article titled 2019 InterQual criteria to be implemented Aug. 1 for non-behavioral health determinations.
| 
