Utilization Management Process

Read more about the Humana Behavioral Health utilization management process and how it determines patient care.

Care Management

Utilization management is the process by which Humana Behavioral Health evaluates the medical necessity and appropriateness of proposed care in order to promote quality, cost-effective care for a member or their family.

Accreditation

Humana Behavioral Health conducts utilization review in accordance with all applicable state laws, rules and regulations, accreditation standards and specific requirements of our individual health plan clients. Humana Behavioral Health is accredited by URAC and the National Committee for Quality Assurance (NCQA).

Levels of Care

Humana Behavioral Health recognizes six (6) distinct levels of care, each with specific criteria for admission, continued stay and discharge. The first level of care is self-help or social services. The remaining five (5) levels of care are considered formal treatment and may qualify for third-party payment by a health plan. Those five (5) levels of care are routine outpatient, intensive outpatient, partial hospitalization (or day hospital), residential treatment and acute inpatient care.

Getting Help

In order to access care, enrollees can call an account-designated toll-free number. When an enrollee calls, their eligibility is determined and their demographic data obtained. The call is then passed to a clinical care manager who conducts a brief assessment. The care manager helps determine the nature of the member's problem and discusses treatment options with him or her. The care manager can also assist in selecting a network provider close to the member’s home or work.

Emergency, Urgent and Routine Care

Humana Behavioral Health makes a distinction between emergency, urgent, and routine care. If it is determined that the member's situation is an emergency, the clinical care manager will work to schedule a session with a network provider within six (6) hours or refer them to the nearest network facility or emergency room for immediate evaluation. If the enrollee and the clinical care manager agree that urgent care is needed, the first appointment for commercial members should be scheduled within 48 hours of the request for services or within 24 hours of the request for services from Medicare or Medicaid members. If the enrollee is requesting more routine services, then Humana Behavioral Health network practitioners should be able to schedule the first session within ten (10) business days of the request.

Certifying Care

Once the member and the clinical care manager have discussed the nature of the problem and the member has selected a practitioner, the care manager will certify that the care meets clinical criteria for medically necessity. The care manager will send a certification letter to the insured and to the practitioner chosen, verifying that specific services have been pre-certified. After the practitioner has been selected for the first visit or after the member has entered a facility, it becomes the network provider's responsibility to contact Humana Behavioral Health with a proposed treatment plan in order to certify any continued treatment. Please note: the certification letter is not a guarantee of payment; it is only verification that the services requested meet medical necessity clinical criteria. Claims payment will be determined at the time the claim is submitted.

Utilization Review

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)

Physician Review

Humana Behavioral Health uses board-certified, licensed psychiatrists to review any cases in which medical necessity may be unclear. If the physician reviewer renders the opinion that the clinical information provided does not meet the medical necessity criteria for continued treatment at that level of care, the care manager will contact the facility or practitioner by telephone to arrange for a peer-to-peer reconsideration. The care manager will schedule a time for the treating physician or practitioner to discuss the case with the Humana Behavioral Health physician reviewer. Based on this conversation, the physician reviewer may authorize continued care or will deny further services at that level of care. Humana Behavioral Health then sends an adverse determination letter to the insured and to the facility or practitioner stating the specific reasons why the services were determined not to be medically necessary. The employee and the practitioner or facility may elect to proceed with the requested service although it may not be covered by the health insurance policy or benefit plan. Participating providers must give the member written notice explaining that the services are not covered by the plan and the member will need to pay for these services. Humana Behavioral Health does not make treatment decisions. Treatment decisions are the responsibility of the patient and provider.

Appeals

If the Humana Behavioral Health physician reviewer determines that the care requested does not meet the medical necessity clinical criteria and sends an adverse determination letter, there are steps the enrollee, practitioner or facility may take to have a different physician reviewer consider the request for services. The enrollee, practitioner or facility may appeal any adverse determination either orally or in writing within 180 days of receipt of the adverse determination. Standard appeals are resolved within 30 calendar days (or 15 calendar days for HMO accounts) Humana Behavioral Health receives the request for the appeal. An expedited appeal is a request for review of emergency care, care for life-threatening conditions, or continued stays for hospitalized patients. An expedited appeal determination is made within 72 hours of the request for appeal. In many states, the enrollee has the right to appeal to the health plan, the state department of insurance, or to an external review organization not affiliated with Humana Behavioral Health. Please note: Some states require a more stringent appeal turn around time. In such cases, Humana Behavioral Health will process the appeal within the state required time frame.

Related Resource

Utilization Management Policies

Guidelines for providers wishing to discuss utilization management denial decisions.Read more

Download and Print

Process for Patient Initiation of an Appeal

Including a description of the availability of an independent external appeal of a utilization management decision made by Humana Behavioral Health.

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