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September 2018

We’re using updated utilization management criteria for behavioral health

On Aug. 6, 2018, Medicare Plus BlueSM PPO, Blue Cross Blue Shield of Michigan’s Medicare Advantage plan, and Blue Care Network’s commercial and Medicare Advantage plans (BCN HMOSM and BCN AdvantageSM) began using the 2018 InterQual® criteria for behavioral health utilization management determinations.

We first communicated about this in June 2018 in a web-DENIS message and a news item at ereferrals.bcbsm.com. These communications indicated that the move to the 2018 criteria would take place on Aug.1, but the date was subsequently changed to Aug. 6.

In addition, certain types of determinations are based on modifications to InterQual criteria or on medical policies, as shown in the table below:

Line of business

Modified 2018 InterQual criteria for:

Medical policy for:

BCN HMO (commercial) and BCN Advantage
  • Substance use disorders: partial hospital program and intensive outpatient program
  • Residential mental health treatment (adult/geriatric and child/adolescent). This benefit is not available to BCN Advantage members.
  • Autism spectrum disorder/ applied behavior analysis
  • Neurofeedback for attention deficit disorder/attention deficit hyperactivity disorder
  • Transcranial magnetic stimulation

Medicare Plus Blue PPO
  • Substance use disorders: partial hospital program and intensive outpatient program

None

Note: Determinations on Blue Cross PPO (commercial) behavioral health services are handled by New Directions.**

Links to the updated versions of the modified criteria, local rules and medical policies are available on the Blue Cross Behavioral Health page and the BCN Behavioral Health page at ereferrals.bcbsm.com.

**New Directions is an independent company that manages behavioral health services for Blue Cross Blue Shield of Michigan.

No portion of this publication may be copied without the express written permission of Blue Cross Blue Shield of Michigan, except that BCBSM participating health care providers may make copies for their personal use. In no event may any portion of this publication be copied or reprinted and used for commercial purposes by any party other than BCBSM.

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2017 American Medical Association. All rights reserved.
Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and
independent licensees of the Blue Cross and Blue Shield Association.