for providers
for providers
 
Provider Online Services

Search

Go

Provider Manual

OUTPATIENT SERVICES (MENTAL HEALTH AND D&A)

Auto Approval for Outpatient Services
Effective May 1, 2010, via ProviderConnect, each provider may request for a consumer up to 72 units of Mental Health Outpatient services and/or Substance Abuse Outpatient services per year prior to the submission of the Outpatient Registration Form (ORF1). This request will be automatically (auto) approved for 72 units for a 12 month period. The request can combine Outpatient services (OUT), Medication Management (RXM), and Evaluations (EXM), but the total number of units can not exceed 72 units. An example of a combined request that works well for many providers is 48 units of OUT, 22 units of RXM, and 2 units of EXM. However, the provider is free to configure the units as best meets the needs of the consumer. The authorization number will be given at the time of submission on the confirmation page, and the authorization letter will be available on ProviderConnect within two-three days after the approval.

Auto Approval for Medication Management Services (RXM)
Effective May 1, 2010, via ProviderConnect, each provider may request for a consumer for up to 24 units of Medication Management (Service Class RXM) for Mental Health and/or Substance Abuse per year prior to the submission of the Outpatient Registration Form (ORF1). This request will be automatically (auto approved) for 24 units for a 12 month period. The authorization number will be given at the time of submission on the confirmation page, and the authorization letter will be available on ProviderConnect two days after the approval.

Auto Approval for Clozapine Support Services (CME, CS1, CS2, PRC)
Effective May 1, 2010, via ProviderConnect, each provider may request for a consumer for up to 104 units of Clozapine Support Services (Service Classes: CME, CS1, CS2, PRC) per year prior to the submission of the Outpatient Registration Form (ORF1). This request will be automatically (auto approved) for 104 units for a 12 month period. The provider is free to configure the units as best meets the needs of the consumer. The authorization number will be given at the time of submission on the confirmation page, and the authorization letter will be available on ProviderConnect within two-three days after the approval.

In the event additional units are needed within the 12 month period, the provider must submit an Outpatient Registration Form (ORF1) either via ProviderConnect or by fax. The ORF1 must be submitted 10 business days prior to the requested begin date on the form. Concurrent authorization visits and timeframes will be based on Medical Necessity Criteria.

Concurrent Reviews
Provider's must submit a completed Outpatient Registration Form (ORF1 and/or Medication Management Registration (Meds Only) form to the Service Center. The forms can be mailed, faxed or submitted electronically through ProviderConnect.

Providers should submit the Outpatient Registration Forms at least 10 business days prior to the date needed. The member's eligibility will then be confirmed and the ORF1 will be reviewed for medical necessity by our Service Center staff. An authorization letter will be available in ProviderConnect detailing the number of sessions granted, the service class authorized, and the timeframe of the authorization period. The provider must submit another Registration Form (ORF1 and/or Medication Management Registration Form) at least 10 business days before the authorization expiration date if further sessions and/or time are needed.

If an Outpatient Registration Form (ORF1 and/or Medication Management Registration Form) are received after the last authorized visit on a continued stay review, then care will only be authorized as of the date the Registration Form (ORF1 and/or Medication Management Registration Form) was received.

Registration Form (ORF1 and/or Medication Management Registration Forms) can be faxed to 855-439-2444, submitted through ProviderConnect, or mailed to:

VBH-PA Service Center
520 Pleasant Valley Road
Trafford, PA 15085
Attn: ORF1 Screeners