Starting Aug. 6, updated utilization management criteria used for behavioral health

Starting Aug. 6, 2018, Blue Care Network and Blue Cross Medicare Plus BlueSM PPO will use the 2018 InterQual® criteria for behavioral health utilization management determinations. The 2017 InterQual criteria will be used until that date.

Note: In earlier messages, we communicated that the 2018 InterQual criteria would be implemented starting Aug. 1, 2018, but that date has been changed to Aug. 6.

For certain services, we will base utilization management decisions on modified 2018 InterQual criteria, local rules or medical policies, instead. These changes will also begin Aug. 6. The services affected by these changes are outlined in this table.

Line of business Modified 2018 InterQual criteria for: Local rules or medical policy for:
BCN HMOSM (commercial) and BCN AdvantageSM
  • Substance use disorders: partial hospital program and intensive outpatient program
  • Residential mental health treatment (adult/geriatric and child/adolescent)
  • Autism spectrum disorder / applied behavior analysis (local rules)
  • Neurofeedback for attention deficit disorder / attention deficit hyperactivity disorder (medical policy)
  • Transcranial magnetic stimulation (medical policy)
Medicare Plus Blue PPO
  • Substance use disorders: partial hospital program and intensive outpatient program

Note: Determinations on Blue Cross PPO (commercial) behavioral health services are handled by New Directions, a Blue Cross vendor.

Links to the updated versions of the modified criteria, local rules and medical policies will be available by Aug. 3 on the Blue Cross Behavioral Health page and the BCN Behavioral Health page on this website. Links to the current criteria are available on those pages until then.

Posted: July 2018
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network