Integrated behavioral health

Whole health means focusing on the whole person. So it just makes sense to integrate medical, mental and behavioral health as equal parts on the health care continuum.

More info

Questions? You can always check your provider manual (PDF) for behavioral health guidelines and other information you need.

If you’re treating a member in crisis, we can help you 24 hours a day, 7 days a week. Just call 1-855-232-3596 (TTY: 711). Members can also call directly.

Questions? You can always check your provider manual (PDF) for behavioral health guidelines and other information you need.

If you’re treating a member in crisis, we can help you 24 hours a day, 7 days a week. Just call 1-855-232-3596 (TTY: 711). Members can also call directly.

Whole health is the goal

Whole health is the goal

We help members and their families by making key connections between medical, mental and behavioral health, as well as disability, wellness and prevention. These are the connections that help members take steps toward whole health.

Behavioral health includes services provided for the assessment and treatment of mental health and substance use disorders (abuse of alcohol and other drugs). Members at risk of or suffering from mental, addictive or other behavioral disorders have access to services to meet their behavioral health needs.

Behavioral health coverage

We cover behavioral health services for members who are:

Eligible for Managed Long-Term Services and Supports (MTLSS)
Clients of the Division of Developmental Disabilities (DDD)
In-inpatient psychiatric or hospital-based detox programs
In ABA/DIR treatment for Autism Spectrum Disorder and under age of 21
In Office Based Addiction Treatment (OBAT) services

Members who aren’t clients of the DDD or MLTSS receive coverage under the Medicaid Fee-for-Service (FFS) program for most behavioral health services.

Providers can call the toll-free number located on the back of the member’s ID card to access:

Information about services
Participating behavioral health providers
Authorization info for members who request services from a behavioral health provider directly

For all members, we also cover the diagnoses of diseases of organic origin categorized as altering the mental status of a member.

Referrals

Member self-referrals

Covered members can self-refer to any mental health/substance use provider in our network without:

Prior authorization (PA)
A referral from their primary care provider (PCP)

PCP referrals

We promote early intervention and health screening to educate members and find behavioral health problems. To that end, we expect network providers to:

Screen, evaluate, treat and/or refer (as medically appropriate) any behavioral health problem or disorder
Treat mental health and/or substance use disorders within the scope of their practice
Tell members how and where to get behavioral health services

Treatment Services for Members with diagnosis of Autism Spectrum Disorder

Treatment Services for Members with diagnosis of Autism Spectrum Disorder

Members under age 21 with a diagnosis of autism spectrum disorder have access to Applied Behavioral Analysis (ABA) or Developmental, Individual Difference, Relationship-Based Model (DIR) services.

To receive ABA or DIR services, the member’s qualified health care professional must complete an assessment and create a proposed treatment plan. Then, you’ll want to submit a prior authorization form by:

Fax: 1-844-797-7601
Phone: 1-855-232-3596 (TTY: 711)

Providers can perform ABA or DIR services:

In their office
In a community setting
In the member’s home
Through telehealth services (during the COVID-19 situation, when you can provide the service with a quality of care equivalent to that of an in-person visit)

Need to learn more? Just check the State Newsletter Volume 30, No. 06 and State Newsletter Volume 33, No. 07. Or call us at 1-855-232-3596 (TTY: 711). You can also see our most recent ABA program rates (PDF) and DIR program rates (PDF).

Guidelines and criteria

When reviewing requests for clinical authorization, our utilization management processes use the most current:

MCG Health guidelines for psychiatric/mental health care

American Society of Addiction Medicine (ASAM) criteria for substance use disorders

In the event of a denial, you can ask for a copy of the relevant guideline or criteria. Just call 1-855-232-3596 (TTY: 711).

Everyone wins with coordination of care

Everyone wins with coordination of care

Working closely with providers to coordinate medical and behavioral care for members ensures appropriate screening, evaluation, treatment and referral for:

Physical health
Behavioral health or substance use disorders
Dual or multiple diagnoses

Developmental disabilities

Sharing info for healthier members

When medical and behavioral health providers work together, members benefit. Our behavioral health and medical providers share information with that goal in mind. This results in appropriate and effective coordination between medical and behavioral health care.

We ask primary care physicians (PCPs) and behavioral health providers to share:

Pertinent history and test results within 24 hours of receipt in urgent or emergent cases
Results for nonurgent or non-emergent lab results within 10 business days of receipt

PCPs screen for behavioral health issues

If you're a PCP, you’ll want to:

Use behavioral health screening tools
Treat behavioral health issues within your scope of practice
Refer members to behavioral health providers, when appropriate

Behavioral health providers screen for physical health issues

If you’re a behavioral health provider, you’ll want to:

Screen members for coexisting medical issues
Refer those who have untreated physical health issues to their PCP (with consent)
Provide physical health care services only if you’re licensed to do so