Pre-Authorization for Mental Health and Substance Abuse Services is Required for Some Services and Helps Avoid Unexpected Out-of-Pocket Costs
Pre-authorization is a process to determine whether a treatment is medically necessary prior to the service being rendered. It also determines whether a treatment or service is the most appropriate and cost-efficient, given a patient’s prior treatment history and standard medical practice. Pre-authorization helps you anticipate which services will be covered and what your out-of-pocket responsibility will be.
When is pre-authorization required for mental health and substance abuse services?
When it comes to mental health and substance abuse services, the Health Plan requires pre-authorization for the following:
- Inpatient hospitalization for the treatment of substance abuse or mental health
- Partial hospitalization for the treatment of substance abuse or mental health
- Residential treatment for substance abuse or mental health
- Intensive outpatient treatment for substance abuse or mental health
Before beginning any of these treatments, have your doctor contact Anthem Blue Cross for a pre-authorization, whether your provider is in or out of network.
How does pre-authorization for mental health and substance abuse services work?
To request pre-authorization, you or your provider must call the Anthem Blue Cross Utilization Management Review Department at (800) 274-7767.
Your provider will be asked to provide certain information to confirm medical necessity—generally, your medical records and a description of the treatment or service being sought. If additional documentation becomes necessary during the review, Anthem will contact your provider.
Once Anthem has completed its review, a decision letter will be sent to both you and your provider. The letter will detail whether pre-authorization is granted in whole or in part—meaning some services might be pre-authorized while others are not—or denied.
In cases when pre-authorization is granted in part or denied, you will need to discuss with your doctor whether to proceed with treatment at your expense for any services not pre-authorized.
What happens if my pre-authorization request is denied?
If your initial pre-authorization request is denied in part or in whole, you will have 180 days to file an appeal with Anthem Blue Cross. If Anthem upholds its original decision, you will have an additional 180 days from that time to file an appeal with the Health Plan.
The details of this two-level appeals process are explained in the decision letters from Anthem.
For more information on the Health Plan’s appeals process, please contact the Plans’ Participant Services Department at (323) 866-2200, Ext. 401, or see Article VIII, Section 4 of the March 2015 Health Plan Summary Plan Description, available at www.dgaplans.org/forms/health.
