We’re making some changes in behavioral health processes beginning Jan. 1

We communicated in previous articles that starting Jan. 1, 2024, Blue Cross Blue Shield of Michigan and Blue Care Network will consolidate the prior authorization and case management functions for behavioral health services, including treatment for autism.

This will affect all members covered by Blue Cross commercial, Medicare Plus Blue℠, BCN commercial and BCN Advantage℠ plans, except those in certain employer groups. Refer to the Mental Health and Substance Use Disorder Carve-Out List for more information.  

The programs are called:

• Blue Cross Behavioral Health℠, which will manage prior authorizations for behavioral health services, including treatment for autism
• Blue Cross^® Coordinated Care℠, which will handle behavioral health case management

These programs will align and standardize prior authorization and case management functions for Blue Cross and BCN members. We expect this consistency across lines of business to simplify processes for health care providers.

Consistent processes

The main benefit for providers is consistency across all lines of business. For example, for dates of service on or after Jan. 1, 2024:

• You’ll use a new provider portal to submit prior authorization requests for all affected Blue Cross and BCN members.
• For autism treatment services, we’ll be revising the requirement to obtain an evaluation through an approved autism evaluation center. (Watch for future communications on this topic.)

FAQ document

We’ve published the Blue Cross Behavioral Health: Frequently asked questions for providers document, which contains many details you’ll need to know.

In the FAQ document, you’ll find important information that will help you navigate this change, including how to submit requests for prior authorization, continued stay reviews and appeals for all dates of service.

We’ll update the FAQ document with additional information as it becomes available.

Key change for Blue Cross commercial prior authorization requests

Starting Jan. 1, 2024, New Directions, now known as Lucet, won’t handle requests for Blue Cross commercial members with dates of service on or after Jan. 1, 2024.

Also, Lucet won’t handle requests related to dates of service before Jan. 1, 2024, a change from what was originally published.

For Blue Cross commercial members, submit requests for prior authorization, continued stay reviews and appeals related to dates of service before Jan. 1, 2024, using one of these methods:

• Email: BHStrategyAppealsandRetrospectiveRequests@bcbsm.com
• Call: 313-225-0329

When you email or call, provide:

• Your name and a contact phone number for you
• The member’s name and contract number
• The date of service you’re inquiring about
• A brief description of what you’re requesting (for example, prior authorization, continued stay review or appeal)

Medical necessity criteria

For dates of service on or after Jan. 1, 2024, Blue Cross Behavioral Health will use the following to make determinations on prior authorization requests:

• Level of Care Utilization System, or LOCUS^®, criteria
• Child and Adolescent Level of Care Utilization System, or CALOCUS^®, criteria
• Early Childhood Services Intensity Instrument, or ECSII, criteria
• The ASAM Criteria^®, from the American Society of Addiction Medicine
• Blue Cross and BCN medical policy for transcranial magnetic stimulation 

Later in 2023, you’ll be able to access these criteria on our Services That Need Prior Authorization webpage at bcbsm.com.

Appeals process

Starting in 2024, the addresses for submitting appeals of prior authorization requests that aren’t approved will change. Refer to the determination letters for the addresses.

Training

We’ll offer training for providers to learn how to access and use the new provider portal to submit prior authorization requests. Watch for more information.