Behavioral Health Program

We provide behavioral health care coverage for our commercial and non-HMO members. Coverage varies according to the member’s benefit plan.

Check eligibility and benefits: Use Availity^® Essentials or your preferred vendor to verify membership and coverage details for every visit.

Behavioral health care management is integrated with our medical care management program. The program helps members access their behavioral health benefits and improves coordination of care between medical and behavioral health providers.

This integration helps our clinical staff identify members who could benefit from coordination between their medical and behavioral health care and may result in:

Improved outcomes
Enhanced continuity of care
Greater clinical efficiencies
Reduced costs over time

We may refer some members* to other programs designed to help identify and close potential gaps in care.

Behavioral health services for Blue Cross and Blue Shield Federal Employee Program^® members are managed by BCBSIL, but different processes may apply. Also watch for exceptions or different processes for Blue Cross Community Health Plans^SM and Blue Cross Community MMAI (Medicare-Medicaid Plan)^SM members. For HMO members, all behavioral health services (mental health and substance use disorders) are managed by the member's Medical Group/Independent Practice Association.

Beginning Jan. 1, 2025, members with Blue Choice Preferred PPO^SM and MyBlue Plus POS^SM individual market benefit plans purchased on or off the marketplace exchange no longer have access to out-of-state care beyond certain border counties. Members may request a waiver prior to services being approved for medical necessity. Learn more here.

All behavioral health benefits are subject to the terms and conditions as listed in the member's benefit plan.

*We may refer members experiencing inpatient hospitalization, complex or special health care needs or who are at risk for medical complications to medical care management programs through a variety of mechanisms such as predictive modeling, claim utilization, inbound calls, self-referrals and physician referrals. If members do not have medical care management programs as part of their group health plans, they will not be referred to other medical care management programs.

Accreditation

Our Behavioral Health Care Management Program is accredited for Health Utilization Management through the National Committee for Quality Assurance. The accreditation is for all our health plans, covering all our members.

About NCQA

NCQA is a private, nonprofit organization dedicated to improving health care quality. NCQA accredits and certifies a wide range of health care organizations. It also recognizes clinicians and practices in key areas of performance.

NCQA’s Healthcare Effectiveness Data and Information Set is the most widely used performance measurement tool in health care. NCQA’s website contains information to help consumers, employers and others make more informed health care choices.

Behavioral Health Care Components

Our Behavioral Health Program provides resources that help members access benefits for behavioral health (mental health and substance abuse) conditions. The Program is part of our overall care management program.

Behavioral Health Program Components

Care and Utilization Management

Inpatient Management — Inpatient, partial hospitalization, and residential treatment center services
Outpatient Management — Management of intensive services which may include services such as: Applied Behavior Analysis, Partial Hospitalization, Intensive Outpatient Program, or Transcranial Magnetic Stimulation.

Case Management Programs

Intensive Case Management — Intervention for members experiencing a high severity of symptoms.
Condition Case Management — Comprehensive coordination of care for members with chronic mental health and substance use conditions,
Active Specialty Management — Support for members with behavioral health needs who do not meet the criteria for intensive or condition case management.
Care Coordination Early Intervention^SM — The CCEI program includes post-discharge outreach to higher risk members who have complex psychosocial needs impacting their discharge plan.

Specialty Programs

Eating Disorder Care Team — A multi-disciplinary clinical team with expertise in treating eating disorders
- Partners with eating disorder experts
- Works with treatment facilities
- Identifies members who may need care and refers to appropriate programs
Autism Response Team — A multi-disciplinary clinical team that provides expertise and support to families seeking autism spectrum disorder treatment. The team works with families to help them maximize their covered benefits.
Risk Identification and Outreach — Our behavioral health, medical, pharmacy and clinical data technology groups work together to help members who may be at risk for substance use disorder. We use information to identify and guide members to clinically appropriate and effective care. RIO works with members who have Prime Therapeutics as their benefits manager.

In addition to the programs above, case managers also refer members to other medical care management programs, wellness and prevention campaigns, if appropriate.

Prior Authorization and Recommended Clinical Review Process

Request prior authorization if required for a particular service. If prior authorization isn’t required, you have the option to submit a request for medical necessity review through our recommended clinical review process.

Checking eligibility and benefits will confirm prior authorization requirements and utilization management vendors, if applicable. All services must be medically necessary.

FEP^® members: Applied Behavior Analysis is the only behavioral health service that requires prior authorization for FEP members.

Commercial members 

Clinicians use the following guidelines to determine whether a requested level of care is medically necessary:

For mental health conditions, MCG Care Guidelines. To access:

Log into AvailityEssentials
Select Payer Spaces from navigation menu and choose BCBSIL
Select the Resources tab
Next, choose Resources in Filter By Category
Select the MCG Care Guidelines link

For addiction disorders, the American Society of Addiction Medicine’s The ASAM Criteria (addiction disorders), our medical policies, nationally recognized clinical practice guidelines and independent professional judgment

Log into Availity Essentials
Select Payer Spaces from navigation menu and choose BCBSIL
Select the Resources tab
Next, choose Resources in Filter By Category
Select the American Society of Addiction Medicine Criteria link

Benefit availability also depends on specific provisions under the member’s benefit plan. Call the number on the member’s ID card if you have questions.

Government program members 

Clinicians use the following hierarchy of clinical criteria to determine the most appropriate level of care for our members: 

National coverage determinations
Local and regional coverage determinations

MCG Care Guidelines (mental health disorders)

Log into Availity Essentials
Select Payer Spaces from navigation menu and choose BCBSIL
Select the Resources tab
Next, choose Resources in Filter By Category
Select the MCG Care Guidelines link

The American Society of Addiction Medicine’s The ASAM Criteria (addiction disorders)

Log into Availity Essentials
Select Payer Spaces from navigation menu and choose BCBSIL
Select the Resources tab
Next, choose Resources in Filter By Category
Select the American Society of Addiction Medicine Criteria link 
Our medical policies
State-specific criteria
Nationally recognized clinical practice guidelines

Prior Authorization

Prior authorization is the process of determining whether the proposed treatment or service meets the definition of “medically necessary,” as set forth in the member’s benefit plan. Prior authorization is obtained by contacting BCBSIL or the appropriate vendor for approval of services before delivering care.

Recommended Clinical Review

Recommended clinical reviews are optional medical necessity reviews conducted before, during or after services are provided. Submitting a request prior to rendering services provides information of situations where a service may not be covered based on medical necessity criteria. The recommended clinical review process evaluates the medical necessity of a service but does not guarantee the service will be covered under the member’s benefit plan.

Verifying Benefits

To determine whether prior authorization is required, verify eligibility and benefits before providing care:

Submit an electronic eligibility and benefits (HIPAA 270) transaction to BCBSIL via Availity Essentials, or through your preferred vendor portal; or
Call the number on the member's ID card.

How to Request Prior Authorization and RCR

To request a prior authorization or recommended clinical review, use one of these methods:

Use the BlueApprovR^SM integrated process through Availity Authorizations to request prior authorization for behavioral health services. Visit our Availity Authorizations and BlueApprovR pages for information.

Availity Authorizations — If BlueApprovR is not applicable, submit requests electronically using the Availity Authorizations tool
Phone — If you are unable to submit a request electronically, call the number on the member’s ID card

Post-Service Utilization Management Review

We may conduct a post-service utilization management review after care is rendered. We review clinical documentation to determine whether a service or drug was medically necessary and covered under the member’s benefit plan.

During post—service reviews, we may request medical records and review claims for consistency with:

Medical policies
Provider agreement
Clinical payment and coding policies
Accuracy of payment

Medical Necessity Criteria

The BCBSIL Behavioral Health team uses nationally recognized, evidence-based and/or state or federally mandated clinical review criteria for all behavioral health clinical decisions. For its group and retail membership, BCBSIL licensed behavioral health clinicians utilize the MCG Care Guidelines for mental health conditions. In addition to medical necessity criteria/guidelines, BH licensed clinicians utilize BCBSIL Medical Policies, nationally recognized clinical practice guidelines (located in the Clinical Resources section of our website) and independent professional judgment to determine whether a requested level of care is medically necessary.

Quality Indicators

Behavioral Health providers have contractually agreed to offer appointments to our members according to specific appointment access standards. Learn more

Quality Improvement Program

Our Behavioral Health Quality Improvement (QI) department continually monitors and evaluates the Behavioral Health Care Management program for BCBSIL to identify enhancement opportunities. Learn more

Government Programs

Different guidelines and processes are in place for behavioral health care and services provided to our government programs members. Learn more

Contact Information

Questions? We’re here to help.

If you have any questions, please contact your provider network representative.

Submit completed Behavioral Health Forms to

Blue Cross and Blue Shield of Illinois BH Unit
PO Box 660240
Dallas, TX 75266-0240
Fax Number: Toll-free 877-361-7659

Claims submission address

Blue Cross and Blue Shield of Illinois
PO Box 660058
Dallas, TX 75266-0058

Blue Cross and Blue Shield Federal Employee Program^®
877-783-1385

Updates about the behavioral health program will be communicated in our Blue Review newsletter.

Related Resources

Checking eligibility and/or benefit information, obtaining prior authorization or the fact that a recommended clinical review decision has been issued is not a guarantee of payment. Benefits will be determined once a claim is received and will be based upon, among other things, the member’s eligibility and the terms of the member’s contract including, but not limited to, exclusions and limitations applicable on the date services were rendered. Regardless of any prior authorization or recommended clinical review, the final decision regarding any treatment or service is between the patient and the health care provider.

MCG Care Guidelines are administered and provided by MCG Health, an independent company that has contracted with Blue Cross and Blue Shield of Illinois to provide care and disease management for members with coverage through BCBSIL. Availity is a trademark of Availity, LLC, a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to BCBSIL. BCBSIL makes no endorsement, representations or warranties regarding third-party vendors and the products and services offered by them.

HEDIS is a registered trademark of the National Committee for Quality Assurance