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HealthPartners

Coverage criteria policies

Access to out-of-network behavioral health services

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan will be used to determine your coverage.

Administrative Process

Prior authorization may be required for specific levels of care and types of behavioral health services.

Members may access out-of-network behavioral health providers when using their out-of-network benefits in many cases without prior authorization.

For behavioral health services or levels of care that require prior authorization, see coverage policies specific to that care. e.g. residential care, substance use disorder treatment

For assistance in finding an in-network provider, members may call the Behavioral Health Network Navigator Line at 952-883-5811 or 1-888-638-8787 weekdays 8:00am – 5:00pm Standard Central Time.

Coverage

Access to out-of-network behavioral health services for evaluation and treatment of mental health and substance use disorders, as described in the most recent version of the Diagnostic and Statistical Manual of Mental Disorders (DSM), are covered per the indications listed below.

Not all benefit plans allow benefit exceptions to cover out-of-network behavioral health providers at the in-network benefit level or have out-of-network benefits to cover out-of-network behavioral health services.

For plans that have out-of-network benefits, the out-of-network benefits are to be used for licensed mental health or chemical health providers that are not in the contracted behavioral health (BH) provider network for your plan.

Indications that are covered at the in-network benefit level

Out-of-network providers may be covered at the in-network benefit level if your benefit plan allows and if the following conditions are met:

  1. The service must be covered under the terms of your benefit plan, and
  2. The service must be medically necessary, and
  3. The services must be provided by a behavioral health professional that is licensed for independent practice, and
  4. The HealthPartners Behavioral Health Utilization Review Department has determined that the service to treat the specific behavioral condition is not available with an in-network BH provider and authorizes the service to be provided outside of the contracted BH provider network.

Out-of-network providers may also be considered for coverage at the in-network benefit level if in addition to the above criteria, one of the following is met;

  1. In the case of a new member who has a pre-existing, ongoing therapeutic relationship with a BH provider who is not in-network, authorized continued care may be considered when transition to an in-network BH provider is likely to result in the patient immediately requiring a higher level of care (such as inpatient treatment), transition is delayed until the patient is clinically stable enough for transfer. These decisions are based on current clinical status and past behavioral health history.
  2. In the case of a request for authorization of coverage for psychological testing or neuropsychological testing with an out-of-network provider, an intake session by an in-network licensed psychologist is required to identify needs for the testing and define the specific questions to be answered by the testing. The licensed psychologist will forward the intake session documentation to the Behavioral Health department for authorization consideration.
  3. In the case of a request for authorization of coverage for specialty care with an out-of-network BH provider, an intake session by an in-network licensed BH provider is required to identify the treatment needs. The in-network BH provider will forward the diagnostic evaluation documentation to the Behavioral Health department for authorization consideration and to determine if the specialty care services are indicated and if those needs can be met in-network.

Indications that are not covered

Referrals out of network will not be made for coverage at the in-network benefit level when one of the following are met:

  1. Care is available to treat the diagnosed condition with an in-network Behavioral Health provider
  2. A new member who has a pre-existing, ongoing therapeutic relationship with an out-of-network provider is not clinically unstable such that a transition to an in-network BH provider is likely to result in immediately requiring a higher level of care.
  3. An intake session by an in-network licensed psychologist has not been conducted to identify needs for psychological or neuropsychological testing with an out-of-network provider and to define the specific questions to be answered by the testing.
  4. An intake session by an in-network licensed BH provider has not been conducted to identify the treatment needs and to determine if specialty BH care services are indicated.

Definitions

In-network Provider - Contracted providers that members can access for in-network coverage under their benefit plan. These providers do not require authorization by the health plan unless the service they provide requires authorization.

Out-of-network Provider – These are providers that are not in the contracted provider network for a member’s plan and are not covered at the in-network benefit level.

Specialty Care – Specialty BH is provided by a BH provider who is licensed for independent practice and has specialty training to treat certain behavioral health diagnoses or populations. E.g. Selective Mutism, pre-school age.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

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Policy activity

  • 10/25/2012 - Date of origin
  • 12/01/2016 - Effective date
Review date
  • 12/2017
Revision date
  • 12/13/2016

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