MEDICAL PROVIDERS: Please review these guidelines for our Outpatient Therapy for Mental Health & Substance Use Disorder medical coverage policy (BI273).
- Mental health therapies require:
- A valid diagnosis
- An evidence-based treatment plan
- Periodic re-evaluation of the treatment’s success
- Adjustments in treatment based on effectiveness
- Therapy services must be prescribed by a physician. If no direct or telemedicine psychiatric evaluation is available, a psychiatric APRN (with a collaborative practice agreement with a psychiatrist) can fulfill this role. If neither a psychiatrist nor a psychiatric APRN is available, a primary care physician is acceptable.
- First 15 psychotherapy visits are covered without pre-authorization. Pre-authorization and a psychiatrist’s individualized written treatment plan are required after initial 15 visits.
- Medically necessary psychotherapy services must be:
- Considered appropriate and needed for the treatment of the disabling or impairing condition.
- Related to a written treatment plan and be restorative, not palliative or habilitative in nature, or be for the purpose of designing a maintenance program to help the patient cope with psychological problems.
- Of a level of complexity that requires the judgment, knowledge and skills of a licensed therapist.
- Frequency and duration of services must be reasonable.
- Treatment plan must be available for review by Care Management if requested.
- One diagnostic evaluation by a psychiatrist per member is covered every 12 months. Any additional psychiatric diagnostic evaluations by the same provider within 12 months require pre-authorization.
- A provider visit solely with the member’s family (except for the legal guardian) is not covered.
