Medical Management and Authorization Programs
Benefits are provided only for medically necessary and appropriate services. (See "Medically Necessary.")
No benefits are payable, however, unless your coverage is in force at the time services are rendered, and payment of benefits is subject to all the terms and requirements of the benefit plan.
Authorization is required for all higher levels of care, including inpatient, Alternate Levels of Care (residential treatment, partial hospitalization, and intensive or structured outpatient care), psychological testing, and electric convulsive therapy (ECT). Authorization establishes that the treatment has met the medical necessity criteria. Your network provider will contact ValueOptions to provide the necessary information on which to base an authorization. If you choose to use a non-network provider, you need to make sure the provider contacts ValueOptions in order to ensure that the services are medically necessary and therefore covered by the plan.
Further, for those enrolled in the NAP or CAP, failure to obtain authorization within 48 hours of confinement or treatment for any higher level of care (that is, inpatient care, partial hospitalization, residential treatment, intensive or structured outpatient care) will result in a $300 penalty. This penalty applies to both Mental Health and Substance Abuse treatment as well as to care provided by either network or non-network providers.
Utilization Review
The Utilization Review process evaluates the on-going medical necessity and appropriateness of care and the setting in which care is provided. Services that are medically necessary and appropriate are certified by ValueOptions and monitored so that you know when it is no longer medically necessary and appropriate to continue those services.
Concurrent Review
The concurrent review process provides authorization for a determined time period depending on the level of care. Prior to the end of the authorization, the provider must contact ValueOptions to provide updated information on which ValueOptions can base its decision to authorize or deny the treatment. Failure to obtain the authorization will result in the claim being denied. Network providers will contact ValueOptions, but non-network providers may need to be reminded to do so. Remember, when using a non-network provider, you are responsible for the payment of services rendered until there is an authorization provided by ValueOptions.
Retroactive Review
The retroactive review process can be used in circumstances in which authorization was not established prior to the services being provided. In that case, you can request the retroactive review and provide written authorization to release the clinical records to ValueOptions. Once the records are received, ValueOptions will review the information and make a determination as whether medical necessity has been established. If medical necessity is not established, then the claims will be denied. If medical necessity is established, the claims will be paid according to the benefit plan provisions; however, there will be a $300 penalty applied for NAP and CAP enrollees if authorization was not obtained.