Behavioral health facilities

Pre-authorization

Pre-authorization

The following services require utilization review (pre-authorization/concurrent review):

  • Inpatient: Psychiatric or ASAM 4.0 detoxification
    • Notification of admission must be received within 24 hours of admission or the next business day (whichever comes first). Medical necessity review will be conducted.
  • Sub-acute detoxification/ASAM level 3.7
    • Requires pre-authorization before the member is admitted for services. Under certain circumstances, pre-authorization requests can be made within 24 hours of admission or the next business day.
  • Residential treatment: Psychiatric or ASAM level 3.5 for substance use disorders
    • Requires pre-authorization before the member is admitted for services. Under certain circumstances, pre-authorization requests can be made within 24 hours of admission or the next business day.
  • Partial hospitalization: Psychiatric or ASAM level 2.5 for substance use disorders
    • Request for authorization is required no later than the day of admission.
  • Intensive outpatient: Psychiatric or ASAM level 2.1 for substance use disorders

    • Request for authorization is required no later than the day of admission.

For details, view our pre-authorization list, including concurrent review requirements.

Request a pre-authorization

We require forms for initial, concurrent and step-down requests; and discharge confirmation. Initial requests can be submitted through Availity Essentials. See the Forms & policies tab for authorization submission forms. Requests can be submitted through the following:

  • Email: FAXBHRepository@bridgespanhealth.com
  • Fax: 1 (888) 496-1540
  • Submit initial request forms through Availity Essentials

    • Sign in to the Availity Essentials
    • Click: Patient Registration>Authorizations & Referrals>Authorizations
    • Complete the authorization request and attach our initial request form

Submission tips

  • You should only initiate a pre-authorization request when clinical information is available for our clinicians to review.
  • Include contact information for the person who can answer questions or provide additional information, if needed. This allows us to complete our review promptly.
  • If you are asking for a concurrent review past the last covered day, submit the request 24 hours prior to the expiration of the last covered day. This will give us time to process the review timely and provide opportunity to coordinate an appeal, if not approved.

Pre-authorization exceptions

There may be exceptions to obtaining pre-authorization. The seven situations listed below may apply as part of our Extenuating Circumstances Policy Criteria (under Pre-authorization exception):

  • Natural disaster prevented the provider or facility from securing a pre-authorization or providing hospital admission notification.
  • A participating provider or facility is unable to anticipate the need for a pre-authorization before or while performing a service or surgery.
  • A surgery that requires pre-authorization occurs in an urgent/emergent situation. Services are subject to review post-service for medical necessity.
  • The member is unable to communicate (e.g., unconscious) medical insurance coverage. Neither family nor collateral support present can provide coverage information.
  • An enrollee is discharged from a facility and insufficient time exists for institutional or home health care services to receive approval prior to delivery of the service.
  • There is compelling evidence the provider attempted to obtain pre-authorization. The evidence must show the provider followed our policy and that the required information was entered correctly by the provider office into the appropriate system.
  • The member presented with an incorrect member ID card or member number, or indicated they were self-pay and that no coverage was in place at the time of treatment, or the participating provider or facility is unable to identify from which carrier or its designated or contracted representative to request a pre-authorization.

Learn how to:

  • Notify us about an extenuating circumstance (under Pre-authorization exception) prior to claim submission.
  • Appeal a claim that has been administratively denied in the Appeals for Providers section of our Administrative Manual.
Appeals

Request an appeal of a denial

If you have received a denial of a pre-authorization request, please consult the denial letter for any appeal process specific to the member's plan.

By fax

By mail

  • Complete the Provider Appeal Form
  • Mail the appeal form and supporting clinical documentation through certified mail to:

BridgeSpan
Attention: Provider Appeals
P.O. Box 1408
Lewiston, ID 83501-1408

Care management

Request a BridgeSpan case manager for a member

We offer case management free of charge to members who need individualized assistance navigating their behavioral health care. Our case managers are licensed behavioral health professionals who can:

  • Be a direct point of contact with the health plan
  • Coordinate care for members with more complex needs
  • Assist members in locating mental health chemical dependency providers
  • Provide ongoing support, coaching and assistance to members in conjunction with the member's treatment professionals

Facilities and other treatment providers may request a case manager by completing a Care Management Referral Request Form.

A case manager will reach out within three business days of receiving the request.

Forms & policies
HEDIS post-discharge follow-up

HEDIS post-discharge follow-up

The Healthcare Effectiveness Data and Information Set (HEDIS®) behavioral health measure Follow-Up After Hospitalization for Mental Illness (FUH) is a key quality measure that ensures members transition safely from an acute hospital setting back to their home environments. Our goal is to help members receive the post-discharge care they need.

Timely follow-up (within seven days) and effective care coordination help improve outcomes. Care coordination is a vital aspect of good treatment planning. We encourage communication among a member’s providers and the health plan.

These best practices meet the measure’s standard and have proven to be effective in achieving positive outcomes:

  • Follow-up can occur any time between days one and seven; the day of discharge is day zero, and appointments on the day of discharge do not count toward compliance with the measure.
  • Follow-up must occur with a behavioral health provider.
  • Follow-up visits may be held in office, via telehealth or through billable visits by phone.

Qualifying provider types and programs

Provider types

  • Psychiatrist
  • Licensed clinical social worker (LCSW)
  • Licensed marriage and family therapist (LMFT)
  • Licensed professional counselor (LPC)
  • Psychiatric nurse
  • Psychologist

Programs

  • Intensive outpatient (IOP)
  • Partial hospitalization (PHP)

The following provider types and programs are not included in the FUH measure:

  • PCP
  • Drug and alcohol counselor
  • Non-licensed clinicians
  • Support groups

Set patients up for success

By working with us, the member and the member’s family or support system, we can collectively ensure members have successful discharge plans and are able to function to their highest ability when they leave the hospital setting.

Your facility should:

  • Begin follow-up planning at the time of inpatient admission and involve and educate the patient’s family about the follow-up plan
  • Encourage your patients to sign an Authorization to Disclose Protected Health Information form (PDF)
    • Most behavioral health information can be shared among treating providers—even those in different organizations—without a release of information (ROI) for the purposes of coordinating care. Requesting an ROI before coordinating care can delay appropriate care and can lead to poor outcomes. Exception: ROIs are required for coordinating with substance use disorder (SUD) providers or facilities.
  • Discuss the follow-up plan with your patient and the importance of follow-up visits
  • Schedule follow-up appointments, including one within seven days of discharge
  • Ensure accurate post-discharge contact and follow-up information
  • Call your patient to remind them of the follow-up appointment

Our care management team will:

  • Determine a follow-up plan during the inpatient review process
  • Assist in securing follow-up appointments, including locating new providers if needed
  • Offer support by contacting members after their discharge to discuss the follow-up plan
  • Help our members understand the importance of follow-up appointments
  • Encourage timely outpatient follow-up with a licensed behavioral health provider

Read about the FUH measure in our Quality Measures Guide.