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Review & Authorization

At MHN, 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.

REVIEW AND AUTHORIZATION

MHN provides coverage for medically necessary treatment of mental health and substance use disorder illnesses. We use nationally recognized guidelines (InterQual and others) 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 psychologist or other behavioral health professional. To help us identify requests for services that are not medically necessary, though, MHN does require preauthorization for some services. When a service requires preauthorization, MHN reviews the proposed treatment before you receive care.

The following services require preauthorization:

  • Psychological and neurological testing done by MHN network providers and some (depending on the contract with the provider) out-of-network providers
  • Inpatient 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 MHN 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 outpatient settings that meet your medical needs - from care for a few hours per day, several days a week to full day treatment that does not involve an overnight stay (referred to as "alternate levels of care")
  • Travel (for home visits)
  • Methadone maintenance
  • Outpatient detoxification treatment
  • Outpatient electroconvulsive therapy (ECT) or transcranial magnetic stimulation (TMS); the provider or facility providing treatment must contact MHN 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 MHN member services prior to scheduling treatment.

Concurrent review

An MHN care manager will review suggested inpatient or day treatment before you receive services and 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 MHN is unable to perform pre-service or concurrent review - for example in an emergency - we will review treatment after it has occurred before approving benefits. Emergency care will be authorized as long as the "prudent layperson standard" has been met, i.e., it is understandable that a reasonable person with no clinical training would be likely to think, based on observing the symptoms, that emergency treatment was necessary.

MODIFICATIONS AND DENIALS

Covered services will be authorized (pre-service or concurrently) as long as treatment is proceeding an 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.

Coverage for emergency room treatment for a non-emergency (based on the "prudent layperson standard" described above) may be denied. If denied, you will receive a letter explaining why.

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

OUR COMMITMENT TO EXCELLENCE

We stand by our clinical philosophy and we regularly survey members to measure their satisfaction with MHN services and the treatment they receive from their providers.

Oversight for our clinical philosophy is provided by MHN's Clinical Leadership Committee. This group includes representation from MHN's clinical, medical, quality improvement and professional relations leadership. It meets weekly to review our clinical policies, practice guidelines, treatment position papers and provider review methodology. This ensures that our clinical approaches are up to date and that we're working in concert with the treatment community to improve the mental wellbeing and quality of life of MHN's members.

MORE DETAILS ON DETERMINATION CRITERIA

MHN bases all decisions on InterQual Level of Care Criteria, MHN internal criteria, and the Centers for Medicare and Medicaid Services (CMS) National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs), as appropriate.

MHN evaluates and adopts all criteria annually, including McKesson's InterQual Level of Care Criteria; CMS's NCD/LCD National and Local Coverage Determinations; and MHN criteria, including our level of care and treatment criteria, position statements, and standard definitions. MHN'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 MHN 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 Coverge) for details.