Once treatment has begun, the practitioner or facility will contact Humana Behavioral Health with clinical information to support the need for continued treatment. This process is called utilization review. The practitioner may submit this information by telephone or by fax if it is routine outpatient treatment. Utilization review for facility-based care is conducted over the telephone. (A template is included below to help direct the review process.)
The practitioner must supply the diagnosis, the symptoms that cause difficulty in day-to-day functioning, a proposed treatment plan at a specific level of care, and an estimated length of treatment. At each utilization review, if there is medical necessity for the continued services requested, the clinical care manager will authorize more days or visits up to the limits of the member’s benefit plan. Information to assist in the utilization review process may be found by clicking the links below. The first is a brief presentation on facility treatment authorization, discharge planning and continuity and coordination of care. The second is the template to assist in gathering the information necessary for an initial telephonic review.
Facility Treatment Authorization, Discharge Planning and Continuity and Coordination of Care
Sample Initial Clinical Template link (Document will download automatically when link is clicked)