Behavioral health facilities

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 lists, including concurrent review requirements.

Electronically (this is the preferred method)

• Sign in to the Availity Provider Portal
• Click: Patient Registration>Authorizations & Referrals>Authorizations

• Complete the authorization request and attach supporting clinical information for our utilization management clinicians to review, such as:

  • Psychiatric evaluation or intake assessment
  • History and physical/nursing assessment (if available)
  • Any other supporting documents you would like considered, such as letters from outpatient providers, etc.

If you are not able to submit your request through the Availity Portal, you may fax it to: 1 (888) 496-1540. Be sure to submit the same information as noted above, along with the Pre-Authorization Request Form.

• Primary mental health treatment requests:
  • Psychiatric evaluation or intake assessment that includes:
    • Family history
    • Medical history
    • Psychiatric history
    • Mental status exam
    • Substance use history
    • Personal and social history (psychosocial)
    • History of current complaint/clinical status
    • Description of member's current complaint/clinical status
  • History and physical/nursing assessment (if available)
  • Any other supporting documents you would like considered, such as letters from outpatient providers, etc.

• Primary substance use disorders treatment requests:

  • Substance use disorder evaluation or intake assessment that includes:
    • Family history
    • Medical history
    • Psychiatric history
    • Mental status exam
    • Substance use history
    • Personal and social history (psychosocial)
    • History of current complaint/clinical status
    • Description of member's current complaint/clinical status
  • History and physical/nursing assessment (if available)
    • Current vitals
    • Current medical concerns/risks
    • Clinical Institute Withdrawal Assessment (CIWA) or Clinical Opiate Withdrawal Scale (COWS) score, or description of active withdrawal symptoms
  • Any other supporting documents you would like considered, such as letters from outpatient providers, etc.

• Consider only initiating a pre-authorization request when clinical information is available for our clinicians to review. Requesting pre-authorizations without clinical information for us to review still starts our regulatory timeclock, in which we are obligated to render a decision within a set timeframe, whether or not supporting clinical evidence is received. This often results in an avoidable denial and subsequently the need to file an appeal. We understand that receiving such a denial can be burdensome for both providers and members, and we want to help you avoid it wherever possible.
• Let us know who we can contact if we have questions or need additional information. This allows us to complete our review promptly.

• If you will be asking for a pre-authorization extension past the last covered day, consider making that request 24 hours prior to the expiration of the last covered day. This will help give us time to review the extension request and, if not approved, provide opportunity to coordinate an appeal during time that has already been approved.

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.

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

• Complete the Provider Appeal Form
• Fax the completed form and supporting clinical evidence to:
  • Commercial Plans: 1 (888) 496-1542
  • Medicare Advantage Plans: 1 (888) 309-8784
  • Uniform Medical Plan (UMP): 1 (877) 663-7526

• Members may request their own appeals by filling out the Member Appeal Form

By mail

• Complete the Provider Appeal Form

• Mail the appeal form and supporting clinical documentation through certified mail to the applicable address below:

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

Medicare Advantage
Attention: Appeals MSB32AG
P.O. Box 1827
Medford, OR 97501-1827

Uniform Medical Plan (UMP)
Attention: ASO Appeals
P.O. Box 2998
Tacoma, WA 94801-2998

Note: Blue Cross and Blue Shield Federal Employee Program® (BCBS FEP®) appeals are not accepted by fax. They must be mailed to:

Regence - FEP
P.O. Box 1388
Lewiston, ID 83501-9998

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.

• Member Appeal Form
• Provider Appeal Form
• Regence Medical Policy – View Regence policies
• Pre-Authorization Request Form
• Authorization to Disclose Protected Health Information
• The American Society of Addiction Medicine (ASAM) Criteria (PDF)

Clinical Intake Operations

• Phone: 1 (800) 780-7881

• Fax: 1 (888) 496-1540

FEP

• Washington: Contact Premera Blue Cross at 1 (800) 622-1379
• Oregon and Utah: Fax 1 (888) 496-1540

• Idaho: Contact Blue Cross of Idaho at 1 (877) 908-0972

Provider Contact Center

Join our Behavioral Health Provider Advisory Council.