We're using updated utilization management criteria for behavioral health starting Aug. 1, 2019

On Aug. 1, 2019, Medicare Plus BlueSM PPO, Blue Cross Blue Shield of Michigan's Medicare Advantage plan, and Blue Care Network's commercial and Medicare Advantage plans (BCN HMOSM and BCN AdvantageSM) will begin using the 2019 InterQual® criteria for behavioral health utilization management determinations.

In addition, certain types of determinations will be based on modifications to InterQual criteria or on local rules or medical policies, as shown in the table below:

Line of business Modified 2019 InterQual criteria for: Local rules or medical policies for:
BCN HMO (commercial) and BCN Advantage
  • Substance use disorders: partial hospital program and intensive outpatient program
  • Residential mental health treatment (adult, geriatric, child and adolescent members)
  • Applied behavior analysis for autism spectrum disorder: (for BCN HMO only)
  • Neurofeedback for attention deficit disorder and attention deficit hyperactivity disorder
  • Transcranial magnetic stimulation
  • Telemedicine (telepsychiatry and teletherapy)
Medicare Plus Blue PPO
  • Substance use disorders: partial hospital program and intensive outpatient program
 None

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

Links to the updated versions of the modified criteria, local rules and medical policies are available on the Blue Cross Behavioral Health page and the BCN Behavioral Health page on this website.

Posted: May 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network