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Health Care Service Corporation (HCSC) is the parent company of several Blue Cross Blue Shield plans, including BCBS of Illinois, Texas, Oklahoma, New Mexico, and Montana. As a major Blues carrier, HCSC follows similar medical necessity standards as other BCBS entities. Recently, HCSC plans have explicitly embraced the ASAM Criteria for substance use disorder treatment reviews. In fact, effective January 1, 2025, HCSC’s BCBS plans are updating from ASAM 3rd Edition to ASAM 4th Edition for adults in medical necessity determinations (Behavioral Health Substance Abuse Criteria for Utilization | Blue Cross and Blue Shield of Illinois) (continuing ASAM 3.0 for adolescents until further notice). HCSC also uses other guidelines like MCG for general behavioral health, but ASAM is central for SUD. Below, we detail how HCSC’s BCBS plans (IL, TX, OK, NM, MT) handle detox, rehab, outpatient, and MAT authorizations and what billing codes and processes providers should note.
Adoption of ASAM Criteria by HCSC Blue Cross Plans
In their provider communications, HCSC has clearly stated that for SUD services, they use ASAM’s “Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions” to make medical necessity decisions. This applies to inpatient, residential, PHP, IOP – any service that falls under SUD treatment. They even announced aligning with the newest ASAM 4.0 for adults in 2025 (Behavioral Health Substance Abuse Criteria for Utilization | Blue Cross and Blue Shield of Illinois), which shows a commitment to staying current with standards.
For providers, this means that documentation and requests should align with ASAM’s six dimensions and recommended levels of care. HCSC’s utilization reviewers (whether in-house or via a vendor like BCBSIL Behavioral Health) will compare the patient’s clinical picture to ASAM placement criteria:
Do they meet ASAM Level 4 (medically managed intensive inpatient)?
Or Level 3.7 (medical monitoring in residential)?
Or is Level 3.5 sufficient?
Perhaps Level 2.5 (PHP) or 2.1 (IOP) fits better?
The goal is to justify that the chosen level is appropriate and lower levels are either tried or considered insufficient – exactly ASAM’s approach.
For instance, BCBS Oklahoma noted that as of 2024, they move from ASAM 3.0 to 4.0 for adults), emphasizing “the need for integrated care and addressing both mental and physical health in addiction treatment” (Behavioral Health Substance Abuse Criteria for Utilization | Blue Cross and Blue Shield of Oklahoma). So, providers should highlight co-occurring conditions and the integrated services needed (if any) when seeking approval – this resonates with ASAM 4th edition’s focus on holistic care.
Detox (Withdrawal Management) – HCSC/BCBS Criteria
If a member of BCBS IL/TX/OK/NM/MT needs detoxification services, HCSC will use ASAM to decide:
Inpatient hospital detox (Level 4-WM): Approved if patient is at risk of severe withdrawal (e.g., seizures, DTs) or has acute medical needs during withdrawal. Document vital signs, withdrawal scale scores (CIWA, COWS), and any history of complicated withdrawal. Many HCSC plans had historically used Milliman/MCG criteria which require things like “symptoms cannot be managed at lower level” – now with ASAM, the concept is the same, just explicitly ASAM-based.
Residential detox (Level 3.7-WM): If the patient needs 24-hour detox but not full hospital care (no ICU or invasive interventions expected), HCSC may approve detox in a residential facility with medical monitoring. Criteria: moderate withdrawal risk, needs medication and monitoring, but stable enough not to need hospital resources.
Ambulatory detox (Level 2-WM): If safe and feasible, HCSC might direct a patient to outpatient detox. For example, BCBS Illinois might not require prior auth for the first few days of ambulatory detox due to Illinois state law that prohibits PA for the first levels of SUD treatment in some scenarios. Always check state specific mandates: Illinois and Texas have had legislation around PA for SUD (e.g., Illinois law PA 100-1023 removed PA for the first levels of SUD treatment for commercial plans). HCSC must comply, so in IL, initial detox services might not need PA – though utilization review still happens behind the scenes.
Billing codes for detox (HCSC BCBS):
HCSC plans recognize HCPCS H0008, H0009, H0010, H0011 codes for detox. In fact, Aetna’s list (which often aligns with industry) identified those for detox, and BCBS plans use similar coding.
For professional providers, if you are billing for managing detox in an office (ambulatory detox), use E/M codes plus possibly H0014 (ambulatory detox code) if required by plan.
Facilities should use appropriate revenue codes (0116 for chemical dependency detox, for example) and H-codes on UB claims.
HCSC likely does not carve out detox as a separate benefit from other SUD treatment – it’s all under behavioral health. However, note for Medicaid plans in NM or TX run by HCSC, they may have separate requirements under state rules.
Residential/Inpatient Rehab – HCSC/BCBS Criteria
HCSC’s BCBS plans cover Inpatient and Residential rehabilitation when ASAM criteria for those levels are met:
Inpatient rehab (ASAM 3.7) in a hospital or licensed facility with 24-hour nursing and physician availability. Indications: significant medical or psychiatric conditions alongside SUD that require daily medical oversight, or an inability to safely participate in a residential program (non-medical) due to those needs. Example: a patient with uncontrolled diabetes or pregnancy might be better in hospital inpatient rehab.
Residential rehab (ASAM 3.5) in a non-hospital setting: Indications per ASAM/HCSC:
Patient has failed or could not succeed in lower levels (document prior IOP or outpatient attempts, or reasons why those were not viable e.g. no stable housing).
Cravings/relapse potential is high and there’s need for 24-hour structure.
Co-occurring mental health issues that require intensive therapy but are stable enough that they don’t need hospital psych.
Lack of support or triggers in home environment making 24-hr setting crucial (Dimension 6).
HCSC also consider safety and risk: If patient is a risk to self/others, they might require a psychiatric inpatient instead. But if it’s purely substance-driven impairment, residential SUD treatment is the route.
All HCSC plans are subject to state utilization review laws. For example:
Illinois law mandates that insurers cannot impose arbitrary day limits on residential SUD treatment and must use ASAM. BCBSIL accordingly uses ASAM and has no fixed day caps. They do, however, still require periodic reviews to assess progress.
Texas has a law requiring coverage of SUD treatment including inpatient and residential, but with prior auth allowed. BCBSTX uses ASAM for decisions (Update: Behavioral Health Substance Use Criteria for UM) ([PDF] Utilization Management - Blue Cross Blue Shield) (their 2024 update confirms use of ASAM for SUD).
Oklahoma, New Mexico, Montana – follow ASAM; NM for instance under Centennial Care (Medicaid) has specific SUD coverage requirements too.
Billing codes for residential rehab (HCSC BCBS):
H0018 (short-term residential) and H0019 (long-term residential) are standard. BCBSIL’s medical policy system likely expects those codes for SUD residential (some BCBS policies explicitly mention using these codes for RTC).
Revenue code 1001/1002 on UB claims as applicable. Always include the billing provider’s BS ID if needed (some Blues require the specific billing BS ID in 837).
A tip: For BCBSMT, NM etc., check if they use the same claims system as BCBSIL (they often do under BlueCard). Always include the subscriber’s home plan prefix and send claims to the local BCBS per BlueCard rules.
Partial Hospitalization (PHP) & Intensive Outpatient (IOP) – HCSC/BCBS Criteria
HCSC plans cover PHP (ASAM 2.5) and IOP (ASAM 2.1) and use ASAM to justify:
PHP: member needs near-daily structured treatment but not 24-hour care. Typically authorized if stepping down from inpatient or stepping up from IOP when IOP insufficient. Document that the patient has a persistent active issue (cravings, mood instability, etc.) that requires daily monitoring/treatment.
IOP: member needs more than weekly therapy, typically 3 times/week program. ASAM criteria: at least moderate impairment in one or more life areas due to SUD, continued use or high risk of relapse, and a need for skill-building and monitoring that weekly sessions haven’t achieved.
HCSC often requires preauthorization for PHP and IOP. However, check specific states:
Illinois passed a law prohibiting PA for the first level of SUD treatment that a provider recommends. That could be interpreted that if a provider says “patient needs IOP,” the insurer can’t demand PA to start it. However, BCBSIL might still require notification and later utilization review. Actually, BCBSIL in 2019 had to remove PA for the first 14 days of residential and first 6 sessions of IOP due to Illinois law. Verify current rules – as of 2023 that law expanded to any level if provider deems emergent.
Texas, Oklahoma did not ban PA, so BCBS in those states likely still require it.
Given these differences, HCSC may have nuanced rules per state. But across the board, they are aligning with ASAM for deciding who qualifies for PHP/IOP.
Billing codes for PHP/IOP (HCSC BCBS):
BCBS plans use HCPCS S0201 for PHP (per diem) and HCPCS H0015 for IOP (per diem unit).
For example, BCBSIL’s provider manual likely instructs to bill S0201 for PHP days.
Some plans accept CPT 90899 with rev code 0913 for PHP as alternative, but S0201 is simpler.
For IOP, use H0015. If by chance the plan’s system doesn’t recognize H0015 (some older systems might want an alternate code), contact provider support, but since HCSC explicitly lists these codes in communications (Everything You Ever Wanted to Know About Aetna Precertification for Addiction Treatment Billing), it should be fine.
BlueCard: If you treat a BCBSIL patient in another state, use the patient’s BCBSIL ID and your local BCBS will route it. Use the same codes; BlueCard will translate as needed (the Medical Policy for SUD is generally universal for HCSC).
Medication-Assisted Treatment (MAT) – HCSC/BCBS Criteria
All HCSC plans cover MAT for opioid and alcohol use disorders. Under parity and state opioid crisis initiatives, they have removed many prior barriers:
No prior authorization for Naloxone, Buprenorphine, Naltrexone in most cases. BCBSIL, for example, announced removal of PA for Suboxone and generic bupe/naloxone years ago. BCBS Texas similarly removed PA for buprenorphine after a state directive.
HCSC uses ASAM and other guidelines to encourage MAT. It’s considered medically necessary for OUD in virtually all moderate-to-severe cases, and even mild cases if clinically justified. So if you request say residential treatment for a heroin user and mention they will also start buprenorphine, that reinforces the medical necessity (they see a comprehensive plan).
For methadone: If the HCSC plan covers OTP services (some do via vendor, or the member might have to access methadone through state program), they abide by state rules. For instance, Illinois Medicaid (which BCBSIL administers for some plans) must cover methadone without PA. BCBSIL commercial likely covers methadone via single case agreements with OTPs, since OTPs historically didn't take insurance. If you’re an OTP, check if you can contract with HCSC’s BCBS – many now do.
HCSC might have concurrent review for MAT if it’s part of structured treatment (like they may review a patient in an OTP for continued need occasionally). But generally, once stable on MAT, they don’t interfere.
Billing codes for MAT (HCSC BCBS):
Buprenorphine: Pharmacy benefit, no PA. The physician visits for induction can be billed with E/M. If you’re billing an evaluation specifically for MAT, use regular codes; maybe add a modifier HG (opiate detox) if required by Blue (some Blues had that requirement historically, but with new code sets likely not).
Methadone (OTP): If BCBS is paying OTPs, they’ll use H0020 (daily methadone dosing) or the new CMS OTP bundle codes (G1028 etc. – though those are Medicare specific, some commercial might adopt them). Likely, they still use H0020 or weekly bundled code like H0020 billed x number of days.
Naltrexone ER (Vivitrol): Covered under medical (J2315) and pharmacy. PA not usually required, but some plans might want confirmation the patient is opioid-free before Vivitrol (to avoid precip withdrawal) – typically a physician attestation suffices if at all.
Naloxone: Covered as preventive in many states, no cost to member.
Prior Authorization Process for HCSC (BCBS IL, TX, OK, NM, MT)
Providers need to submit prior authorization requests for SUD treatment via the BCBS provider portals or by phone:
BCBS IL/TX have the Availity portal where you can submit behavioral health auths.
For urgent admissions (like an emergency detox), call the number on back of card within 24 hours. HCSC plans abide by the rule that emergency SUD treatment must be covered without prior auth, but you still have to notify them quickly.
When requesting auth:
Use the ASAM criteria language: e.g., “Patient meets ASAM Level 3.5 criteria due to inability to maintain abstinence at lower levels, no stable home, and ongoing cravings and use despite intensive outpatient (Substance Use Disorder Intensive Outpatient Programs).”
Provide objective evidence: drug test results, withdrawal scale scores, treatment history.
Indicate the treatment plan: planned therapies, MAT, family involvement, length of program.
HCSC’s utilization reviewers are often internal clinicians or sometimes a vendor like Magellan or New Directions (BCBSIL Behavioral Health was administered by Prime/Carelon at one point). But as a provider, you just submit to BCBS and they route it appropriately.
Response times: They typically give initial decisions fairly quickly (24-72 hours for non-urgent). Continued stay reviews might require you to submit progress via phone/fax a couple days before auth expiry.
Key: Documentation! Always align to the specific wording of criteria. For example, BCBSOK’s update mentions "multi-dimensional assessments, greater emphasis on integrated care" (Behavioral Health Substance Abuse Criteria for Utilization | Blue Cross and Blue Shield of Oklahoma). So, mention all dimensions and any integrated care aspects (like co-treating medical conditions).
State Mandates:
In Illinois, legislation (Public Act 100-1023) basically forces BCBSIL to approve the first 14 days of inpatient or residential treatment without prior auth if provider certifies medical necessity, and first 30 outpatient sessions (inclusive of IOP). BCBSIL must be notified but cannot deny those initially. After those periods, they can review. So, for IL providers, be aware: you can initiate treatment immediately and then notify BCBSIL. They might do a concurrent review instead of prospective auth.
Texas, etc., don’t have such laws, so PA as normal.
Appeals and Peer Review:
If HCSC denies or partially approves and you disagree, request a peer-to-peer with their medical director promptly. Often it’s a Blue Cross physician or a psychiatrist/addiction specialist contracted to them. Be ready to argue using ASAM – for example, “I understand you believe patient could step down to IOP, but per ASAM Dimension 5, his relapse risk remains high and per Dimension 6 he lacks a sober environment, making residential still necessary at this time.”
If that fails, utilize the formal appeals. HCSC has an internal appeal and then external review process. External reviewers will also use ASAM and often side with providers if criteria were met and insurer denied wrongly.
Billing and Coding for HCSC – Key Points
HCSC’s BCBS plans process claims either directly or via BlueCard when out of area. Some considerations:
Always include the member’s correct prefix and ID; SUD claims often go to the behavioral health carve-out if it exists (some HCSC plans carve in BH, others outsource to Magellan – check member card).
Use exact codes authorized. If auth is for H0018, don’t substitute another code.
Modifiers: If required by state, e.g., Illinois Medicaid requires certain modifiers for provider level, but commercial generally not.
Place of Service (POS): Use POS 22 for PHP (outpatient hospital), POS 57 for non-residential substance abuse facility (some use 57 for IOP), POS 55 for residential substance abuse facility. Correct POS helps them adjudicate correctly.
BlueCard billing: If you’re out-of-state:
Send claim to your local Blue plan. They forward to home plan (HCSC).
Use standard codes. Home plan (HCSC) will apply their rates/edits and return it.
Any denials come back through local plan EOB.
Follow-up:
HCSC is generally prompt, but if claims linger, use the provider portal to check status.
If a claim denies for no authorization but you had one, supply proof of auth number and dates in an appeal or call – sometimes data mismatches cause denials.
In conclusion, HCSC’s BCBS plans require that providers align with ASAM Criteria for demonstrating medical necessity. They require prior auth for most SUD services (with some state exceptions for initial care). They are increasingly standardized across their states: as shown by identical updates in IL, TX, etc. about adopting ASAM 4.0 (Behavioral Health Substance Abuse Criteria for Utilization | Blue Cross and Blue Shield of Illinois). Providers should leverage that by citing ASAM directly and ensuring documentation is exhaustive and multidimensional.
For more insights on working with Blue Cross/Blue Shield plans, consider reading BehaveHealth’s blog about Top 10 Insurance Companies and covering care – which highlights strategies for dealing with large insurers like Anthem, Aetna, and the Blues (How to Get the Top 10 Insurance Companies to Cover Care for Your Patients). It emphasizes relationship-building and understanding each payer’s quirks. Specifically for HCSC Blues, building a rapport with their care managers and understanding state-specific rules (like Illinois’ no-PA mandate for initial treatment) can significantly smooth the authorization and billing process.