Behavioral Health

At Health Net, our clinical philosophy revolves around our commitment to providing prompt access to the right care. We support your behavioral health providers' efforts to deliver the best possible outcomes by collaborating with them to identify effective treatment plans and by following fair and consistent review, authorization and (if necessary) modification or denial processes.

Note: Always consult your plan documents (in California, your Evidence of Coverage) for a detailed benefit description, including a description of which benefits or services are subject to these processes. Not all plans require preauthorization or concurrent reviews for the same benefits or in the same circumstances.

Health Net provides coverage for medically necessary treatment of mental health and substance use disorder issues. We use nationally recognized guidelines to review clinical records and proposed treatment plans to see that:

• The level of care requested is appropriate based on your symptoms
• The plan is based on clinical evidence, and has a reasonable probability of providing a positive outcome
• Long-term outcomes are considered
• Treatment is prescribed for the least restrictive setting possible

Upon review, at any stage, care may be authorized/approved, modified or denied. We use the following methods as part of this process:

Pre-service review and preauthorization

Preauthorization is not required for most covered outpatient services, such as office visits with a therapist, psychiatrist or other behavioral health professional. Health Net Behavioral Health does require preauthorization for some services. When a service requires preauthorization, Health Net Behavioral Health reviews the proposed treatment before you receive care.

The following services require preauthorization:

• Psychological and neuropsychological testing done by Health Net Behavioral Health network providers and out-of-network providers (in certain circumstances)
• Inpatient and residential treatment (treatment at a hospital or other overnight care facility), except in an emergency. (If you need emergency inpatient treatment, you or a family member or your doctor or hospital must call Health Net Behavioral Health within 24 hours of admission. We'll make sure that your benefits are in place and assign a case manager to offer support.)
• Treatment in other settings that meet your medical needs – for example, partial hospitalization or intensive outpatient
• Outpatient electroconvulsive therapy (ECT) or transcranial magnetic stimulation (TMS); the provider or facility providing treatment must contact Health Net Behavioral Health for preauthorization
• Applied Behavioral Analysis (ABA) and related treatment plans and reports

If you have questions about whether or not you need preauthorization, please call behavioral health member services prior to scheduling treatment.

Concurrent review

An Health Net Behavioral Health care manager will review your care on a regular basis for the duration of your treatment. This is called "concurrent review," and it is designed to ensure that patients are always receiving care in the most appropriate (least restrictive and most cost effective) setting.

Post-service review

When Health Net Behavioral Health is unable to perform pre-service or concurrent review - for example in an emergency - we will review treatment after it has occurred in order to determine whether or not the services were medically necessary.

Modifications and Denials

Covered services will be authorized (pre-service or concurrently) as long as treatment is proceeding in a clinically appropriate manner. When we believe a requested service is not medically necessary or that a proposed treatment should be reconsidered, we work with your provider to consider alternatives. We collaborate with your provider to resolve any differences in clinical judgment, and decisions are based on what is best for you, the patient, with consideration for your long-term needs. If we cannot approve services, we will send you a letter clearly explaining the reason for modification or denial and recommending alternatives.

As a member, you always have the right to appeal modification and denial decisions.

Medical Necessity Criteria

Health Net Behavioral Health bases all decisions on criteria set forth by non-profit professional associations (outlined below), Health Net internal criteria, and the Centers for Medicare and Medicaid Services (CMS) National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs), as appropriate.

Health Net Behavioral Health evaluates and adopts all criteria annually. Health Net Behavioral Health's medical directors and peer reviewers review each case on its own merits and make an individualized, multi-factorial decision based on the appropriate level of care and treatment criteria.

The information on this website is only a summary of the processes Health Net uses to authorize, modify or deny benefits. Details may vary based on your individual treatment needs and your specific plan benefits. Please consult your plan documents (in California, your Evidence of Coverage) for details.

For Information and training offered by the nonprofit professional associations listed above, please visit the following links: (Pease note by clicking the links below you will be leaving the Health Net website)

American Academy of Child & Adolescent Psychiatry – Level of Care Utilization System (LOCUS) / Child and Adolescent Level of Care Utilization System

• About the criteria: LOCUS – American Association for Community Psychiatry
• Training site: Welcome to LOCUS Online

American Society of Addiction Medicine (ASAM)

• About the ASAM Criteria
• ASAM Criteria for Patients and Families (PDF)
• ASAM Training site

Early Childhood Service Intensity Instrument (ECSII)

• About the ECSII criteria
• Training site: Educational Toolkits, Readings, and Webinars

The Council of Autism Service Providers (CASP)

• About the Criteria: Autism Spectrum Disorder Guidelines – Council of Autism Service Providers
• Training site: CASP CEU Center

_{¹ Examples of non-physician mental health providers include counseling professionals, substance abuse professionals and qualified autism service providers.}