Who is Blue Shield of California and What is Their Track Record with Behavioral Health Utilization Reviews?

While they’ve done things like make nominal financial contributions to the cause of diversifying the mental healthcare profession, Blue Shield of California is part of a general trend in managed care to minimize costs for insurers by limiting the scope of “medical necessity,” especially when it comes to addiction treatment.

 Overall, Blue Shield of California is working to push addiction treatment and mental health care into more affordable spaces, like digital tools that minimize behavioral healthcare costs for insurance companies. 

Another way Blue Shield of California cuts costs - or “manages liabilities” - is to require prior authorizations, utilization reviews and concurrent reviews for inpatient stays. Together, these practices are referred to as “utilization management” at Blue Shield of California. At Behave Health, we’ve found that each of these processes eats up valuable resources at addiction treatment centers, where billing departments must often jump through many hoops to ensure that patients get the care that they deserve. 

Blue Shield of California, however, contends that their Utilization Management program is primarily for the benefit of the patient. They also claim on their website that there are “no financial incentives” behind any decisions made by “UM decision-makers:”

 Our UM decisions are made by qualified medical staff and are based only on appropriateness of care and service, and existence of coverage (i.e., medical necessity within contracted benefits). Blue Shield does not specifically reward practitioners or other individuals (e.g., medical groups or doctors’ employees) for issuing denials of coverage or service area. There are no financial incentives for UM decision-makers and therefore, Blue Shield does not encourage decisions that result in underutilization.

What Clinical Guidelines Does Blue Shield of California Use When Performing Utilization Reviews? 

Blue Shield of California uses various well established clinical guidelines when considering whether or not they will reimburse for addiction treatment care. Here’s a list of guidelines that their Utilization Management team draws from when conducting a UR:

• ASAM criteria 

• Level of Care Utilization System guidelines 

• Child and Adolescent Level of Care Utilization System guidelines

• Early Childhood Service Intensity Instrument guidelines 

• World Professional Association for Transgender Health guidelines 

• “Other nonprofit organizations’ guidelines” in keeping with the California Mental Health Parity Act

How Does Blue Shield of California Define Medical Necessity When it Comes to Addiction Treatment? 

In addition to implementing the above clinical guidelines during a utilization review, Blue Shield of California checks to see that the proposed addiction treatment plan meets the following criteria: 

• Agrees with “generally accepted standards” of behavioral health care 

• Nature and duration of treatment is “clinically appropriate” 

• The treatment is principally designed to treat the patient and is not designed principally for the the financial gain or convenience of the provider or the patient 

Where Can I Direct Questions About Utilization Reviews for Blue Shield of California and Addiction Treatment or Behavioral Healthcare?

You can reach Blue Shield of California’s UM staff at 1-800-541-6652 (press option 6 when you get to the menu) or you can fax them at 844-807-8996. Unfortunately, there is no way to email the UM Team at Blue Shield of California. However, if you call or fax them, the UM team can help answer your UR questions and also provide you with more information about the UM criteria that Blue Shield of California uses during addiction treatment utilization reviews. 

Confused by Blue Shield of California’s Utilization Review Process for Addiction Treatment? We Can Help.

Completing in-house utilization reviews with Blue Shield of California is usually an expensive time waster for busy addiction treatment centers and providers.

BehaveHealth’s Revenue Cycle Management (RCM) service includes soup-to-nuts, hyper-detailed, hands-on attention to every single component of your addiction treatment billing needs. We have strong working relationships with every major insurance company in the United States. 

Even better, we’re not health care generalists.  We only work for behavioral health providers like you.

Let our team of specialists handle it all: 

• Verification of Benefits 

• Utilization Review 

• Billing and Collections 

• Patient Responsibility

• Denials and Appeals 

Get your free trial started today and see why more addiction treatment centers prefer Behave Health.