ALERT! Admission to a Residential Treatment Center (RTC) must be preauthorized.
The plan covers mental health services for treatment of neuropsychiatric, mental, and personality disorders, including eating disorders. Marriage or family counseling is not covered.
Your provider must notify the plan upon admission when you receive the following services:
Partial Hospitalization Program (PHP)
ALERT! Inpatient mental health treatment is subject to clinical review.
Services are considered "inpatient" when you are admitted to a facility.
The plan pays for these services according to the network status of the provider, unless your condition is a medical emergency. All covered professional services are paid based on the allowed amount.
Outpatient mental health services are covered the same as any other medical service. The plan pays based on the allowed amount and the network status of the provider.
Preauthorization for outpatient mental health services is not required in most cases. However, the plan may require that your provider submit a treatment plan in order to determine medical necessity. The plan will review your provider's treatment plan to determine if the following conditions are met:
The purpose of the service is to treat or diagnose a medical condition;
Outpatient services are the appropriate level of services considering the potential benefits of the services;
The level of service is known to be effective in improving health outcomes; and
The level of service recommended for your condition is cost-effective compared to alternative interventions including no intervention. See the definition of "Medically Necessary Services, Supplies, Drugs, or Interventions."
ALERT! Services must be provided by a covered provider type.