Beacon Health Options | Provider Handbook | i
TABLE OF CONTENTS
1. Introduction ............................................................................................................................................... 9
1.01 Overview ........................................................................................................................... 9
1.02 About Beacon .................................................................................................................. 10
1.03 Contact Information ......................................................................................................... 11
2. E-Commerce Initiative ............................................................................................................................. 12
3. Electronic Resources .............................................................................................................................. 13
3.01 CAQH .............................................................................................................................. 13
3.02 ProviderConnect .............................................................................................................. 13
3.03 Electronic Claim Submission and Clearinghouses .......................................................... 13
3.04 Payspan .......................................................................................................................... 14
3.05 Beaconhealthoptions.com ............................................................................................... 14
3.06 Achieve Solutions ............................................................................................................ 14
3.07 eServices ......................................................................................................................... 15
3.08 Communications .............................................................................................................. 15
4. Participating Providers ............................................................................................................................ 15
4.01 Beacon Provider Identification Numbers ......................................................................... 16
4.02 Provider Satisfaction Survey ........................................................................................... 16
4.03 Changes to Beacon Provider Records ............................................................................ 17
4.04 Policies and Procedures .................................................................................................. 17
5. Credentialing and Re-Credentialing ........................................................................................................ 18
5.01 Credentialing ................................................................................................................... 18
5.02 Re-Credentialing ............................................................................................................. 19
5.03 Standards ........................................................................................................................ 20
5.04 Site Visits ......................................................................................................................... 21
5.05 Updates ........................................................................................................................... 21
5.06 Delegation ....................................................................................................................... 22
6. Sanctions ................................................................................................................................................ 22
7. Appeals of National Credentialing Committee/Provider Appeals Committee Decisions ........................ 24
7.01 Professional Review Activities/Fair Hearing Process ...................................................... 25
8. Office Procedures ................................................................................................................................... 26
8.01 Member Rights and Responsibilities ............................................................................... 26
8.02 Confidentiality, Privacy, and Security of Identifiable Health Information ......................... 27
8.03 Appointment and Availability Standards .......................................................................... 27
8.04 Out-of-Office Coverage ................................................................................................... 28
8.05 Termination and Leave of Absence ................................................................................. 29
8.06 Catastrophic Event .......................................................................................................... 29
8.07 Requests for Additional Information ................................................................................ 29
9. Services to Members .............................................................................................................................. 29
9.01 Emergency Services ....................................................................................................... 31
9.02 Referrals .......................................................................................................................... 31
9.03 EAP Transition to Health Plan Benefits ........................................................................... 31
Beacon Health Options | Provider Handbook | ii
9.04 Coordination with Primary Care/Treating Providers ........................................................ 31
9.05 Continuation following Provider Agreement Expiration or Termination ........................... 32
9.06 Certain Regulatory Requirements ................................................................................... 33
9.07 Fraud, Waste, and Abuse ................................................................................................ 33
10. Participating Provider Complaints, Grievances, and Appeals .............................................................. 34
10.01 Complaints Regarding the Provider Agreement ............................................................ 34
10.02 General Complaints and Grievances ............................................................................. 34
11. Claims Procedures and E-Commerce Initiative .................................................................................... 35
11.01 E-Commerce Initiative ................................................................................................... 35
11.02 Member Expenses ........................................................................................................ 35
11.03 Preauthorization, Certification, or Notification ............................................................... 36
11.04 No Balance Billing ......................................................................................................... 36
11.05 Claim Submission Guidelines ........................................................................................ 36
11.06 Required Claim Elements .............................................................................................. 38
11.07 Requests for Additional Information .............................................................................. 39
11.08 Claims Processing ......................................................................................................... 39
11.09 Provider Summary Vouchers......................................................................................... 39
11.10 Coordination of Benefits ................................................................................................ 40
11.11 Overpayment Recovery ................................................................................................. 40
11.12 Requests for Review ..................................................................................................... 41
11.13 Claims Disputes ............................................................................................................ 41
11.14 Claims Billing Audits ...................................................................................................... 41
11.15 Appeal ........................................................................................................................... 43
11.16 Reporting Fraud, Waste, and Abuse ............................................................................. 44
12. Utilization Management ......................................................................................................................... 44
12.01 New and Emerging Technologies .................................................................................. 45
12.02 Treatment Planning ....................................................................................................... 46
12.03 Clinical Review Process ................................................................................................ 46
12.04 Retrospective Review .................................................................................................... 47
12.05 Definition of Medical Necessity...................................................................................... 48
12.06 Medical Necessity Criteria ............................................................................................. 49
12.07 Clinical Practice Guidelines ........................................................................................... 50
12.08 Beacon’s Care Management System ............................................................................ 50
12.09 Clinical Care Manager Reviews .................................................................................... 51
12.10 Inpatient or Higher Levels of Care ................................................................................. 53
12.11 Discharge Planning ....................................................................................................... 54
12.12 Case Management Services (For select patients who meet high-risk criteria) .............. 55
12.13 Adverse Clinical Determination/Peer Review ................................................................ 55
12.14 Telehealth ...................................................................................................................... 57
12.15 Outpatient Services ....................................................................................................... 57
12.16 Appeal of Adverse Determinations ................................................................................ 57
12.17 Clinical Appeals ............................................................................................................. 59
12.18 Administrative Appeals .................................................................................................. 62
12.19 Final Appeal Level ......................................................................................................... 62
13. Quality Management/Quality Improvement........................................................................................... 62
13.01 Quality Management Committees ................................................................................. 63
Beacon Health Options | Provider Handbook | iii
13.02 Quality Management Program Overview....................................................................... 63
13.03 Role of Participating Providers ...................................................................................... 64
13.04 Quality Performance Indicator Development and Monitoring Activities ......................... 64
13.05 Service Availability and Access to Care ........................................................................ 65
13.06 Healthcare Effectiveness Data and Information Set (HEDIS
®
) ...................................... 66
13.07 Continuity and Coordination of Care ............................................................................. 72
13.08 Screening Programs ...................................................................................................... 72
13.09 Treatment Record Standards and Guidelines ............................................................... 73
13.10 Treatment Record Reviews ........................................................................................... 74
13.11 Member Safety Program ............................................................................................... 76
13.12 Professional Review/Fair Hearing Process ................................................................... 78
13.13 Quality Improvement Activities/Projects ........................................................................ 78
13.14 Experience Surveys (formerly known as Satisfaction Surveys) .................................... 79
13.15 Member Complaints and Grievances ............................................................................ 79
Appendices
Appendix 1: Handbook Glossary
Appendix 2: List of Forms and Reference Documents
Medical Necessity Criteria
Clinical Practice Guidelines
Resource Documents
Appendix 3: State/Government Program/Network Specific Provision and/or Supplements
Appendix 4: Medicare Advantage Specific Provisions
Appendix 4A: New York State Specific – Medicare Advantage/Medicare-Medicaid Dual
Eligible Required Provisions (Fully Integrated Duals Advantage (FIDA))
Appendix 5: EAP Handbook
Appendix 5A: MOS Handbook
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1. INTRODUCTION
1.01 Overview
Welcome to Beacon’s
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network of participating providers. This handbook is an extension of the provider
agreement and includes requirements for doing business with Beacon Health Options, Inc. and its
affiliates and subsidiaries, including policies and procedures for individual providers, affiliates, group
practices, programs, and facilities. Requirements for doing business with Anthem, Inc. health plans can
be found at https://www.anthem.com/provider/policies.
Together, the provider agreement, addenda, and this handbook outline the requirements and procedures
applicable to participating providers in the Beacon network(s).
Italicized terms are terms included in the Glossary section of this handbook located in Appendix 1.
Forms referenced in this handbook or in the provider agreement are available for download or printing
through the ‘Beacon Health Options Providers’ section of the website.
Important Notice: Except to the extent a given section or provision in this handbook is included to
address a regulatory, accreditation, or government program requirement or specific benefit plan
requirement, in the event of a conflict between a member’s benefit plan, the provider agreement, and this
handbook, such conflict will be resolved by giving precedence in the following order:
1. The member’s benefit plan
2. The provider agreement
3. This handbook
This handbook replaces in its entirety any previous version and is available electronically on the website.
Changes and updates to this handbook, member educational materials, news, and other online services
are posted and/or available through the ‘Beacon Health Options Providers’ section of the website.
Changes and updates become binding 60 days after notice is provided by mail or electronic means, or
such other time as may be identified for compliance with statutory, regulatory, and/or accreditation
requirements to which Beacon is or may be subject.
Links to the website, other information, and forms referenced throughout this handbook are included for
convenience purposes only and such information and/or forms are subject to change without notice.
Participating providers should access and download the most up-to-date information and/or forms from
the website at the time needed.
Questions, comments, and suggestions regarding this handbook should be directed to:
Beacon Health Options
National Provider Service Line
800-397-1630
Mon. through Fri., 8 a.m. to 8 p.m. ET
1
Any use of or reference to “Beacon” or to “Beacon Health Options” in any communication, publication, notice,
disclosure, mailing or other document, whether written or electronic, requires the prior written authorization of
Beacon.
2
This handbook applies to participating providers in provider network(s) maintained by Beacon Health Options, Inc.
and the following subsidiaries: Beacon Health of California, Inc.; ValueOptions of Kansas, Inc.; and CHCS IPA, Inc.
CHCS IPA, Inc. is an independent practice association operating only in New York and is a wholly owned
subsidiary of Beacon Health Options, Inc.
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1.02 About Beacon
While Beacon Health Options, Inc. is licensed in numerous states as a third-party administrator and/or
utilization review agent of behavioral health services, some of Beacon Health Options, Inc.’s affiliates and
subsidiaries are licensed as full service or limited service health plans operating in a designated state.
Beacon Health Options of California, Inc., ValueOptions of Kansas, Inc., CHCS IPA, Inc., are all
subsidiaries of Beacon Health Options, Inc. For purposes of this handbook, references to “Beacon” shall
mean, individually or collectively, as applicable, the Beacon legal entity with whom the provider has
contracted to provide services with respect to a member.
Beacon, through contracts with clients, manages and/or administers behavioral health and wellness
benefits and services, including employee assistance programs (EAP), work/life services, wellness
programs, and mental health and substance use disorder benefits and services in a wide array of
settings. Today, clients include employer groups, commercial/exchange health plans, Medicare
Advantage and managed Medicaid health plans, and state and local government programs and agencies.
Additional information about Beacon is available on the website.
Beacon manages mental health and substance use disorder services of benefit plans sponsored and/or
administered, in whole or in part, by companies and organizations contracted with Beacon in compliance
with applicable laws, rules, and regulations, including without limitation the Federal Mental Health Parity
and Addictions Equity Act, Affordable Care Act, state parity laws, and regulations. Subject to benefit plan
requirements, inpatient covered services and other higher levels of care generally require prior
authorization/certification or notification of the admission. Outpatient covered services are reviewed for
medical necessity when clinical factors indicate possible non-evidenced based practice or the need for
additional interventions. Certain high-risk or complex cases may require prior review and/or more
intensive review and/or case management. Details of individual benefit plan requirements and procedures
are available through ProviderConnect, Beacon’s secure, HIPAA-compliant website designed specifically
for providers.
Beacon’s mission is to help people live their lives to the fullest potential. Our values guide the way we
treat our members, providers, clients, and each other. They are the heart of all we do. A number of
Beacon’s regions or Engagement Centers sponsor consumer self-help groups, educational programs,
drop-in centers, advocacy programs, and other consumer-led activities that help people become actively
involved in achieving their highest possible level of functioning in their communities.
Beacon arranges for the provision of and access to a broad scope of behavioral health services for
members through its provider networks, consisting of appropriately licensed and/or certified practitioners,
facilities, providers, and programs offering varying levels of service.
Beacon does not specifically offer rewards or incentives, financial or otherwise, to its utilization
management staff, contractors, participating providers, Clinical Care Managers (CCMs), Peer
Advisors, or any other individuals or entities involved in making medical necessity determinations
for issuing denials of coverage or service or that are intended to encourage determinations that
result in underutilization. Utilization management decisions are based solely on appropriateness
of care and service, existence of coverage and utilizing the medical necessity criteria approved
for use by Beacon.
Information specific to participating providers in EAP networks is located in Appendix 5 on the website.
Contact information for Beacon is located in this handbook. Additional information about the locations,
email addresses, and toll-free numbers of Beacon’s offices throughout the country are conveniently
located on the website.
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1.03 Contact Information
Administrative Appeal
To request an administrative appeal, call the toll-free number included
in the administrative denial letter received.
Potential Quality of Care
(PQOC) Concerns
Report all Potential Quality of Care Concerns (PQOC) to Beacon
immediately and within 24 hours using the clinical form available on
Beacon’s website at
https://www.beaconhealthoptions.com/providers/beacon/forms/clinical-
forms/ or follow local notification processes when applicable.
Changing your Provider
Profile (e.g., name,
address)
To change or update your Provider Profile (e.g., address), the
preferred method to do so is through the “Update Demographic
Information” option in ProviderConnect.
Providers without access to ProviderConnect can call Beacon’s
National Provider Service Line at 800-397-1630, Mon. through Fri., 8
a.m. to 8 p.m. ET.
Note: Updating a Tax ID requires an accompanying W-9 form, which
can be uploaded as an attachment in ProviderConnect. A copy of the
W-9 form is available on the website.
Claims
For general claim inquires, call 800-888-3944.
For technical questions related to direct claim submission via
ProviderConnect or batch submission, please contact the EDI
Helpdesk at:
Telephone: 888-247-9311 from 8 a.m.-6 p.m. ET
Fax: 866-698-6032
Email: e-supportservices@beaconhealthoptions.com
For providers who are unable to submit a claim electronically, paper
claims should be sent to the address referenced on the member’s
benefit plan, as addresses may vary.
Beacon Health Options’ Payer ID is BEACON963116116.
Clinical Appeals
To request a clinical appeal on a member’s behalf, call the toll-free
number included in the adverse determination letter received.
Complaints/Grievances
To file a complaint/grievance, call the toll-free number on the
member’s identification card to speak to customer service.
Credentialing
To obtain information pertaining to network participation status,
contact Beacon’s National Provider Service Line at 800-397-1630
Mon. through Fri., 8 a.m. to 8 p.m. ET.
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To send supporting documentation such as malpractice or insurance
cover sheets, please fax to 866-612-7795.
Fraud and Abuse
Report questionable billing practices or suspected fraud to:
Beacon Health Options, Inc.
ATTN: Corporate SIU
1400 Crossways Blvd, Ste 101
Chesapeake, VA 23320
SIU@beaconhealthoptions.com
Beacon’s National Provider Service Line at 800-397-1630, Mon.
through Fri., 8 a.m. to 8 p.m. ET.
Member Benefits,
Eligibility, and
Authorizations
For questions about member eligibility or benefits, providers can
submit an inquiry via ProviderConnect by selecting “Eligibility and
Benefits.” For questions about authorization status, providers can
select the “Review an Authorization” option via ProviderConnect.
For additional questions about authorizations or benefits, call the toll-
free number on the back of the member’s identification card.
Member Customer Service
To reach member customer service, call the toll-free number on the
back of the member’s identification card.
Provider Coverage During
Absences
To update Beacon if there will be lack of provider coverage due to
absences (e.g., coverage while on vacation), contact the CCM with
whom the participating provider conducts reviews during absences, or
call the number on the member’s card to provide coverage
information.
2. E-COMMERCE INITIATIVE
Providers in the Beacon network are encouraged to conduct all routine transactions electronically,
including:
Submission of claims
Submission of authorization requests
Verification of eligibility inquiries
Submission of re-credentialing applications
Updating of provider information
Electronic fund transfer/direct deposit through PaySpan
®
Provider claims and authorization status checks
Reviewing claims remittance information
To conduct these transactions referenced above, Beacon encourages providers to utilize the resources
detailed further in the handbook sections titled “Electronic Resources,” “Claim Procedures,” “Re-
13
credentialing and Credentialing” and “Updating Provider Information.” These resources will expedite
claims processing and facilitate administrative tasks.
For questions or further assistance regarding this recommendation, please email your Regional Provider
Relations team or call the Beacon National Provider Service Line at 800-397-1630 Monday through
Friday, 8 a.m. to 8 p.m. ET. Regional Office email addresses are located under “Contact Information” on
the website.
3. ELECTRONIC RESOURCES
The following electronic solutions are available to assist providers in complying with Beacon’s E-
Commerce initiative:
3.01 CAQH
All participating providers are encouraged to register and participate with CAQH
®
, including attesting on a
regular basis, to reduce the credentialing timeline and improve directory accuracy. CAQH is an industry
standard solution to capture and share health care self-reported information that 1.4 million health care
providers use today—97 percent of Beacon’s individual providers are already registered. Beacon
accesses information from CAQH as updates are made to provider data. Be sure to give “Beacon Health
Options” permission to access CAQH content.
3.02 ProviderConnect
ProviderConnect is a secure, password-protected portal where participating providers conduct certain
online activities with Beacon directly 24 hours a day, seven days a week (excluding scheduled
maintenance and unforeseen systems issues). Currently, participating providers are provided with access
to the following online activities:
Authorization or certification requests for all levels of care
Concurrent review requests and discharge reporting
Claim status review for both paper and electronic claims submitted to Beacon
Verification of eligibility status
Submission of inquiries to Beacon’s provider customer service
Updates to practice profiles/records
Electronic access to authorization/certification letters from Beacon
Provider summary vouchers (PSVs)
Links to information and documents important to providers are located on the ProviderConnect page of
our website.
Note: Use of E-Commerce solutions offered by Beacon is recommended.
3.03 Electronic Claim Submission and Clearinghouses
Beacon has contracted with Availity Essentials (“Availity”) as our primary clearinghouse. All providers and
facilities that generate HIPAA compliance 837 files will need to register with Availity and submit their files
14
through Availity’s web portal. The Availity portal also offers direct data entry of claim records using both
professional and institutional claim formats.
Providers and facilities that are submitting through a clearinghouse other than Availity (i.e. Change
Healthcare, Office Ally) can continue to do so as all existing clearinghouse trading partners will be routing
claims through Availity to Beacon.
For information about testing and setup for EDI, review Beacon’s 837 companion guide available on
Beacon’s website. Beacon accepts standard HIPAA 837 professional and institutional health care claim
transactions and provides 999 and 277CA response.
3.04 Payspan
Beacon providers/participating providers must use Payspan for electronic fund transfer. Payspan enables
providers to receive payments automatically in their bank account of choice, receive email notifications
immediately upon payment, view remittance advices online, and download an 835 file to use for auto-
posting purposes.
3.05 Beaconhealthoptions.com
Beacons website, www.beaconhealthoptions.com contains information about Beacon and its business.
Links to information and documents important to providers are located in the ‘Beacon Health Options
Providers’ section, including additional information pertaining to Beacon’s E-Commerce Initiative.
Access to this handbook is available on the website as well.
Beacon’s Privacy Policy is located on the website.
Note: The website Privacy Policy, including but not limited to limitations on liability and warranties, apply
to the installation and use of, and any technical assistance related to the installation or use of this
software. Technical assistance includes but is not limited to any guidance, recommendations,
instructions, or actions taken by Beacon or its employees, including where such activity is performed
directly on your system, device, or equipment by a Beacon employee or other representative.
3.06 Achieve Solutions
Achieve Solutions is Beacon’s educational behavioral health and wellness information website. As this
website is educational in nature, it is not intended as a resource for emergency crisis situations or as a
replacement for medical care or counseling. The website includes self-management tools and other
resources that can support members.
When members can self-identify risk factors or health issues early on, they can proactively take steps to
improve their health and reduce potential risk factors. Offering self-management tools encourages
members to monitor, track, and take charge of their own behavioral and/or physical health conditions.
Beacon offers member-specific self-management tools and educational content on its Achieve Solutions
platform, which you can find on the Beacon Health Options website under Member Health Tools.
Topics include (but are not limited to):
• Adult BMI Calculator
• Reducing High-Risk Drinking
• Increasing Physical Activity
• Integrated Care: Taking Charge of Your Health
• Do You Have a Nicotine Addiction?
• Are Your Weight Management Habits Healthy?
15
• Managing Stress in Your Life
• Identifying Common Emotional Concerns
• How Well Do You Bounce Back from Life’s Challenges?
We encourage you to promote the use of this award-winning website with the individuals you serve.
3.07 eServices
eServices is a secure, password-protected portal used by certain health plans contracted with Beacon.
Participating providers using this portal can conduct certain online activities with Beacon directly 24 hours
a day, seven days a week (excluding scheduled maintenance and unforeseen systems issues). Currently,
participating providers are provided with access to the following online activities:
Check real-time claim status
Print explanation of benefit (EOB) information
Check member eligibility
Check initial encounters used
Request authorizations
Check the status of authorizations, including units used
Update practice and clinician information
View or print provider documents such as manuals, forms, or bulletins
Generate and print reports
eServices transactions take less time to complete than paper submissions, enabling providers to improve
productivity. Fax transmission problems, mail delays, and most errors are eliminated by using eServices,
thereby reducing provider administrative staff burden.
Links to information and documents important to providers are located on the eServices page of our
website.
3.08 Communications
Beacon regularly communications with participating providers via email. Communications include
regulatory requirements, protocol changes, helpful reminders regarding claim submission, and other
topics. To receive communications in the most efficient manner, we strongly encourage providers to
maintain accurate contact information, especially valid email addresses, on file with Beacon.
Beacon uses email encryption when communicating protected health information (PHI) and personally
identifiable information (PII). If provider/participating provider does not use email encryption, Beacon
recommends sending PHI or PII to Beacon through our provider portals or by secure fax. Be aware: It is
a HIPAA violation to include any member identifying information or PHI in non-secure email through the
Internet.
4. PARTICIPATING PROVIDERS
Beacon does not refuse to contract or terminate existing contractual relationships with providers because
a provider:
16
Advocates on behalf of a member
Files a complaint with or against Beacon
Appeals a decision or determination made by Beacon
Participating providers are independent contractors of Beacon. This means that participating providers
practice and operate independently, are not employees of Beacon, and are not partners with or involved
in a joint venture or similar arrangement with Beacon. Beacon does not direct, control, or endorse health
care or treatment rendered or to be rendered by providers or participating providers.
Beacon encourages participating providers/providers to communicate with members to discuss available
treatment options, including medications and available options, regardless of coverage determinations
made to or to be made by Beacon or a designee of Beacon. Treating providers, in conjunction with the
member (or the member’s legal representative), make decisions regarding what services and treatment
are rendered. Any preauthorization, certification, or medical necessity determinations by Beacon relate
solely to payment. Participating providers/providers should direct members to Beacon or their respective
benefit plan representatives for questions regarding coverage or limitations of coverage under their
benefit plan prior to rendering non-emergency services.
4.01 Beacon Provider Identification Numbers
The Beacon provider number is a provider’s/participating provider’s unique number assigned by Beacon.
Some contracts will assign a provider number specific to that contract that includes an alpha prefix. The
provider number identifies a provider in the Beacon system and is used for giving access to
ProviderConnect. The provider number is on file with Beacon. Providers/participating providers should
contact the Beacon National Provider Services Line at 800-397-1630, Mon. through Fri., 8 a.m. to 8 p.m.
ET for questions regarding Provider Identification Numbers and/or for assistance in obtaining a Provider
Identification Number.
The provider’s service location vendor number is a number that identifies where services are or were
rendered. A participating provider may have multiple vendor locations and each vendor location is given a
five-digit number preceded by a letter (e.g., A23456, D45678).
The pay-to vendor number is a vendor number issued by Beacon and indicates the mailing address for all
payments and also when using our electronic payments service through PaySpan. A provider can have
more than one pay-to vendor number and each number needs to be registered with PaySpan.
The National Provider Identifier (NPI) is a unique 10-digit identification number issued to health care
providers in the United States by the Centers for Medicare and Medicaid Services (CMS). The NPI is
different from a Beacon-assigned provider number. The NPI is a provider identifier that replaces the
different identifiers used in standard electronic transactions. HHS adopted the NPI as a provision of
HIPAA. This number is also contained in the Beacon system and can be used to locate a provider record
for claims, referrals, and authorization purposes.
4.02 Provider Satisfaction Survey
Beacon conducts an annual provider satisfaction survey to measure participating providers’ opinions
regarding Beacon’s clinical and administrative processes. Data is aggregated, trended, and used to
identify improvement opportunities. Results are reviewed with the Executive Leadership Team (ELT),
Corporate Quality Committee (CQC), Quality Leads, Provider Relations Leads, and Provider Quality
Management. A formal written improvement plan is developed by Beacon to identify and act on
17
improvement opportunities. Departments and regions work in collaboration with the national
network/provider relations team on improvement activities.
4.03 Changes to Beacon Provider Records
Information about participating providers’ physical addresses and locations, billing addresses, hours of
operation, clinical specialties, and licensure or certification status are used in credentialing and re-
credentialing activities as well as in provider directories and listings made available to clients and
members. Participating providers must notify Beacon in advance of changes or updates to information
provided to Beacon.
Changes and updates to participating provider information and records should be submitted to Beacon
via ProviderConnect. If changes to a Tax ID are necessary, there is a W-9 form accessible through the
website.
At the time of recredentialing, participating providers should make changes to information previously
submitted to Beacon and contained in their Beacon Provider Record through ProviderConnect or CAQH.
Failure to report changes in a timely manner can adversely affect participation in the network and may
result in delayed claims payments.
4.04 Policies and Procedures
Pursuant to the terms of the provider agreement, participating providers must comply with Beacon’s
policies and procedures and as outlined in this handbook. Certain policies and procedures may apply only
to a designated line of business or type of benefit plan or government sponsored health benefit program;
a list of these is located in Appendix 3.
The CMS requires Medicare Advantage plans to include certain terms and provisions in provider
agreements and in policies and procedures. Appendix 4 includes references to specific regulatory
requirements and guidelines about participation in networks available to Medicare Advantage plans.
As more specifically detailed in other parts of this handbook, Beacon maintains continuous quality
improvement and utilization management programs that include policies and procedures and measures
designed to provide for ongoing monitoring and evaluation of services rendered to members (e.g., clinical
review criteria, member and participating provider surveys, evaluations, and audits). Participating provider
involvement is an integral part of these programs. Participating providers must cooperate with and
participate in Beacon’s quality improvement and utilization management programs and activities. Refusal
to cooperate with Beacon’s quality improvement and/or utilization management activities may adversely
affect continued network participation status or result in sanctions up to and including termination of
network participation status.
In addition, some Beacon clients establish procedures and requirements unique to benefit plans offered
or administered by that client or to a specific government health benefit program. Therefore, in addition to
careful review of the information provided in this handbook, it is very important to review any client and/or
network specific requirements located in the ‘Beacon Health Options Providers’ section of the website.
Detailed information about a specific member’s benefit plan requirements can be obtained by viewing a
member’s benefits on the ‘Benefit’ tab in ProviderConnect.
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5. CREDENTIALING AND RE-CREDENTIALING
Beacon’s credentialing processes for new providers seeking to contract with Beacon and re-credentialing
processes for participating providers currently contracted with Beacon are designed to comply with
national accreditation standards to which Beacon is or may be subject, as well as applicable state and/or
federal laws, rules, and regulations. Credentialing and re-credentialing is required for all providers and
participating providers, respectively, including without limitation individual practitioners and organizations
(clinics, facilities, or programs). All provider/participating provider office or facility locations where services
are rendered and that share the same federal tax identification number that are identified in credentialing/
re-credentialing applications will be considered for participation status under that application.
Providers and participating providers are credentialed and re-credentialed, respectively, for participation
status for designated services, level(s) of services and practice sites. Should participating providers have
other or additional services, levels of services or practice sites available, additional credentialing and/or
re-credentialing may be necessary prior to designation as a ‘participating provider’ for such additional
services, levels of services or practice sites. Services, levels of services or practice sites for which a
participating provider is not credentialed for are subject to all applicable out-of-network authorization,
certification, and any benefit or coverage limitations under the member’s benefit plan.
As provided for in Beacon’s policies and procedures, decisions to approve or decline initial credentialing
applications, to approve re-credentialing applications, and/or to submit a given credentialing or re-
credentialing application for further review are made by the Beacon Health Options National Credentialing
Committee (NCC), or where applicable by a local Beacon established credentialing committee.
Participating providers have the right to:
Request review of information submitted in support of credentialing or re-credentialing
applications
Correct erroneous information collected during the credentialing or re-credentialing processes
Request information about the status of credentialing or re-credentialing applications
All requests to review information must be submitted in writing. Verbal requests for the status of a
credentialing or re-credentialing application can be made by calling the Beacon National Provider
Services Line at 800-397-1630, Mon. through Fri., 8 a.m. to 8 p.m. ET. Regardless of the above, Beacon
will not release information obtained through the primary source verification process where prohibited by
applicable state and/or federal laws, rules, and/or regulations.
5.01 Credentialing
Initial credentialing processes begin with submission of completed and signed applications, along with all
required supporting documentation using one of the following methods:
After completing the online universal credentialing process offered by the Council for Affordable
Quality Healthcare (CAQH), give Beacon access to your credentialing information and ensure a
current attestation. Call the CAQH Help Desk at 888-599-1771 for answers to your questions
related to the CAQH application or website.
Complete a Beacon paper or online application by calling the Beacon National Provider Services
Line at 800-397-1630.
This includes without limitation attestation as to:
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Any limits on the provider’s ability to perform essential functions of their position or operational
status
With respect to individual practitioner providers, the absence of any current illegal substance or
drug use
Any loss of required state licensure and/or certification
Absence of felony convictions
With respect to individual practitioner providers, any loss or limitation of privileges or disciplinary
action
The correctness and completeness of the application
Failure of a provider to submit a complete and signed credentialing application, and all required
supporting documentation timely and as provided for in the credentialing application and/or requests from
Beacon, may result in rejection of request for participation status with Beacon.
Once the participating provider has been approved for credentialing and contracted with Beacon as an
individual practitioner, group member, or facility, Beacon will advise of the effective date for specified lines
of business.
Once the facility has been approved for credentialing and contracted with Beacon, all licensed or certified
behavioral health professionals listed may treat members for applicable services and lines of business.
The credentialed facility is responsible for credentialing and overseeing its clinical staff as Beacon does
not individually credential facility-based staff.
5.02 Re-Credentialing
Re-credentialing for participating providers is required every three years, or such shorter period of time
where required by a specific state law or regulation. The process for re-credentialing begins
approximately three months prior to the end of the initial credentialing cycle or the preceding re-
credentialing cycle, as applicable, and can be accomplished using one of the following methods:
After completing the online universal credentialing process offered by the Council for Affordable
Quality Healthcare (CAQH), give Beacon access to your credentialing information and ensure a
current attestation. Call the CAQH Help Desk at 888-599-1771 for answers to your questions
related to the CAQH application or website.
We will mail a re-credentialing application via USPS to the participating provider or notify the
participating provider via email, voicemail, or fax that their online re-credentialing application is
available via ProviderConnect.
Required documentation includes without limitation attestation as to
Any limits on the participating provider’s ability to perform essential functions of their position or
operational status
With respect to individual practitioner participating providers, the absence of any current illegal
substance or drug use
The correctness and completeness of the application (including without limitation identification of
any changes in or updates to information submitted during initial credentialing)
Failure of a participating provider to submit a complete and signed re-credentialing application, including
all required supporting documentation timely and as provided for in the re-credentialing application and/or
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requests from Beacon, may result in termination of participation status with Beacon and members are
transitioned to in-network providers Such providers may be required to go through the initial credentialing
process.
5.03 Standards
Standards applicable to providers in the initial credentialing process and to participating providers in the
re-credentialing process include, but are not limited to the following:
Current, unencumbered (not subject to probation, suspension, supervision and/or other
monitoring requirements), and valid license to practice as an independent provider at the highest
level certified or approved by the state or states in which services are performed for the
provider’s/participating provider’s specialty (individual practitioners)
Current, unencumbered (not subject to probation, suspension, supervision and/or other
monitoring requirements), and valid license to practice and/or operate independently at the
highest level certified or approved by the state or states in which services are performed for the
provider’s/participating provider’s facility/program status (organizations)
Accreditation currently accepted by Beacon for organizations* (currently TJC, CARF, COA, HFAP,
AAAHC, NIAHO, CHAP, and AOA)
Clinical privileges in good standing at the institution designated as the primary admitting facility,
with no limitations placed on the ability to independently practice in his/her specialty (individual
practitioners)
Graduation from an accredited professional school and/or highest training program applicable to
the academic degree, discipline, or licensure (individual practitioners)
Current specialty board certification, if indicated on the application (individual practitioners)
A copy of a current Drug Enforcement Agency (DEA) certificate and/or Controlled Dangerous
Substance (CDS) Certificate where applicable (individual practitioners)
No adverse professional liability claims which result in settlements or judgments paid by or on
behalf of the provider/participating provider which disclose an instance of, or pattern of, behavior
which may endanger members
Good standing with state and federal authorities and programs (organizations)
No exclusion or sanctions from government-sponsored health benefit programs (e.g.,
Medicare/Medicaid) (individual practitioners and organizations)
Current specialized training as required for certain levels or areas of specialty care (individual
practitioners)
Malpractice and/or professional liability coverage in amounts consistent with Beacon’s policies
and procedures (individual practitioners and organizations)
An appropriate work history for the provider’s/participating provider’s specialty (individual
practitioners)
* Structured site visits are required for all unaccredited organizations.
Changes or updates to any of the above noted information is subject to re-verification from primary
sources during the re-credentialing process, or at the time of notice of such a change or update from the
participating provider. Additionally, providers/participating providers must have:
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No adverse record of failure to follow Beacon’s policies and procedures or quality management
activities
No adverse record of provider actions that violate the terms of the provider agreement
No adverse record of indictment, arrest or conviction of any felony or any crime indicating
potential or actual member endangerment
No criminal charges filed relating to the participating provider’s ability to render services to
members
No action or inaction taken by participating provider that, in the sole discretion of Beacon, results
or may result in a threat to the health or well-being of a member or is not in the member’s best
interest
5.04 Site Visits
In addition, and as part of credentialing or re-credentialing, Beacon may conduct a structured site visit of
provider’s/participating provider’s offices/locations. Site visits include, but may not be limited to, an
evaluation using the Beacon site and operations standards and an evaluation of clinical recordkeeping
practices against Beacon’s standards.
The current Beacon site visit tool is available for review on the website. As the site visit tool is subject to
modification without notice, participating providers are encouraged to check the website for the most
current site visit tool prior to scheduled site visits. While Beacon, at its discretion, may require a site visit
in the course of credentialing and/or re-credentialing processes based on information submitted and/or
obtained in the process, site visits will be conducted for providers/participating providers in the following
categories:
Unaccredited organizations
Site visits required by a Beacon client as part of credentialing/re-credentialing activities delegated
to Beacon
Providers/participating providers with two or more documented member complaints in a six-month
time frame relating to physical accessibility, physical appearance, adequacy of waiting/examining
room space, or alleged quality of care issues
Site visits are arranged in advance. Following the site visit, Beacon will provide a written report detailing
the findings, which report may include required monitoring where applicable and/or requirements for the
participating provider to submit an action plan.
5.05 Updates
Providers/participating providers are required to report material changes to information included in
credentialing and/or re-credentialing applications submitted to Beacon. Except as noted below, all such
changes must be reported in writing within the time period provided for in the provider agreement, but not
to exceed 10 calendar days of the provider/participating provider becoming aware of the information.
Failure to comply may result in immediate termination of network participation status. The following is a
list (not exhaustive) of examples of the types of material changes for which the above report is required:
Any action against licenses, certifications, registrations, and/or accreditation status*
Any legal or government action initiated that could materially affect the rendering of services to
members
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Any legal action commenced by or on behalf of a member
Any initiation of bankruptcy or insolvency proceedings, whether voluntary or involuntary
Any other occurrence that could materially affect the rendering of services to members
Discovery that a claim, suit or criminal or administrative proceeding is being brought against the
provider/participating provider relating to the provider’s delivery of care (i.e., a malpractice suit),
compliance with community standards and/or to applicable laws, including but not limited to any
action by licensing or accreditation entities and/or exclusions from a government-sponsored
health benefit program (e.g., Medicare/Medicaid)
* The suspension, revocation, expiration and/or voluntary surrender of professional license/certification,
DEA certificate, CDS certificate, and/or board certification must be reported within five calendar days of
the effective date of the action. (Contact Beacon to coordinate the transition of members to the care of
other participating providers where licensure/certification no longer meets Beacon’s credentialing/re-
credentialing standards and/or requirements pursuant to state and/or federal laws regarding the
provision of services.)
Note: If a participating provider moves to or expands their practice and/or operations into another state,
a copy of the participating provider’s license/certification and malpractice/professional liability coverage
is required in order to complete primary source verification and credential the participating provider to
treat Beacon’s members in another state.
Expiration, non-renewal and/or decrease in required malpractice or professional liability coverage must be
reported 30 days prior to such change in coverage.
Any changes in demographic or contact information or changes in practice patterns, such as change of
services and/or billing address, name change, coverage arrangements, tax identification number, hours of
operation, and/or changes in ownership, must be provided to Beacon in advance of such changes.
Beacon must receive 60 days’ advance notice of any new programs or services offered by a facility
provider in order to allow for completion of the credentialing process prior to provision of services to
members.
Changes in ownership and/or management of participating providers may require negotiation and
execution of consent to assignment and assumption agreements as related to provider agreements and
the parties to provider agreements.
5.06 Delegation
Should Beacon, in its sole discretion, elect to delegate any credentialing and/or re-credentialing activities
to a participating provider, such delegation is subject to all applicable policies and procedures, state and
federal laws, rules and/or regulations, accreditation standards to which Beacon is or may be subject, and
any client and/or government program specific requirements. Reference to possible delegation herein in
no way obligates or requires Beacon to consider delegation of any credentialing and/or re-credentialing
activities.
6. SANCTIONS
While efforts are made to resolve provider/participating provider credentialing/re-credentialing issues
and/or quality issues through consultation and education, occasionally further action is necessary to
provide for quality service delivery and protection of members. Sanctions may be imposed for issues
related to member complaints/grievances, credentialing/re-credentialing issues, professional competency
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and/or conduct issues, quality of care concerns/issues, and/or violations of state and/or federal laws,
rules and/or regulations. Beacon’s processes comply with all applicable local, state and/or federal
reporting requirements regarding professional competence and/or conduct. The provider agrees to screen
any employee, temporary employee, volunteer, consultants, governing body member, vendors prior to
hire or contract, and monthly thereafter against U.S. Department of Health and Human Services Office of
Inspector General’s List of Excluded Individuals/Entities & Most Wanted Fugitives, the System for Award
Management, and any other list of individuals excluded from participation in any Federal or State health
care program and disclose to Beacon all exclusions and events that would make them ineligible to
perform work related, directly or indirectly, to federal health care programs. Subject to modification based
on the facts and circumstances in a given case, the following is a list of possible sanctions that may be
imposed on participating providers by the NCC, any Beacon local credentialing committee, and/or the
Beacon Provider Appeals Committee (PAC). The descriptions below are not in any specific order and
should not be interpreted to mean that there is a series of sanctions; any one or more possible sanctions
described below may be imposed in any order or sequence.
TYPE
DEFINITION
Consultation
A call is placed to notify the participating provider of the alleged action or
incident. The participating provider will be provided with an explanation of
possible sanctions if corrective actions are not taken. The call will be
documented to include the date and subject for consultation. A copy of the
consultation will be placed in the participating provider's file. Appropriate
educational materials will be sent via certified mail.
Written Warning
A written notice is sent to the participating provider notifying him/her of the
alleged action or incident. Possible sanctions, if corrective actions are not
taken, will be explained. A copy of the letter is retained in the participating
provider’s file; educational material is sent via certified mail. Corrective
action will be monitored as necessary.
Second Warning/
Monitoring
At the discretion of the Medical Director, a second written notice may be
sent to the participating provider and a copy of such letter shall remain in
the participating provider’s file. Additionally, the participating provider may
be placed on monitoring when data indicates nonconformance with
standards; and, if Beacon determines it is in the members' best interest,
Beacon may elect to suspend new member referrals, new member
authorizations and/or redirect all current members to other participating
providers. The participating provider will be given written notice (and
where applicable notice of fair hearing rights) via certified mail of the
issues for which the participating provider is being monitored. A copy of
the letter is placed in the participating provider's file.
Facility/Program Participating Providers: An action plan will be
provided consisting of steps that, when taken, will remedy the deficiencies
or concerns that created the need for monitoring. The participating
provider is expected to use best efforts to comply with the monitoring
action plan. If an action plan has been sent, the participating provider is
expected to notify Beacon in writing of the status of the issue for which
monitoring was initiated at the end of the action plan timeline, or sooner if
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TYPE
DEFINITION
applicable. The participating provider is expected to keep Beacon updated
in writing of all changes in the issue/concern that triggered monitoring.
Suspension
The participating provider may be suspended from network participation
pending resolution of issues raised. Suspension requires NCC action.
During suspension, Beacon may elect to suspend new member referrals,
new member authorizations and/or redirect all current members to other
participating providers. The participating provider will be notified by written
notice via facsimile and certified mail of the issues for which the
suspension occurred. A copy of the letter is placed in the participating
provider’s file. The suspension may last for a period of 30 calendar days
during which time an investigation may take place. The NCC may extend
this time period as necessary to gather additional information.
Individual Participating Providers: The suspension may last for a period
of up to 30 calendar days during which time an investigation may take
place. The NCC may extend this time period as necessary to gather
additional information.
Termination
The participating provider may be terminated from the network.
Termination requires NCC action. The participating provider will be given
written notice via facsimile and certified mail that the participating provider
is being terminated from the network and the reason for the termination. A
copy of the letter is put in the participating provider's file. Members in care
will be notified and given assistance for referral to a new participating
provider for continuing care, as necessary.
7. APPEALS OF NATIONAL CREDENTIALING
COMMITTEE/PROVIDER APPEALS COMMITTEE DECISIONS
The NCC and Beacon’s local credentialing committees will give providers/participating providers written
notice of the committee’s decision regarding credentialing or re-credentialing applications submitted, any
sanctions imposed or recommended, the reason for the decision, and of the provider’s/participating
provider’s right to appeal adverse decisions along with an explanation of the applicable appeals
procedure(s). Unless otherwise identified in such written notice, providers/participating providers have 30
calendar days from the date of the committee’s notice of an adverse decision to file a written request for
an appeal.
Provider/participating provider appeals of adverse credentialing/re-credentialing decisions of a Beacon
local credentialing committee may be appealed to the NCC.
The NCC:
Functions as a peer review body under NCQA standards
Is made up of representatives from major clinical disciplines and includes participating providers
Makes the final decision regarding:
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o Beacon credentialing/re-credentialing policies and procedures
o Approval/denial/pending status for credentialing/re-credentialing applications
o Determinations regarding possible participating provider sanctions identified above
Provider/participating provider appeals of adverse credentialing/re-credentialing decisions of the NCC
may be appealed to the Beacon Provider Appeals Committee (PAC). The PAC is comprised of
representatives of major clinical disciplines, participating providers, and clinical representatives from
corporate departments within Beacon, none of whom have participated in the original NCC adverse
decision under review.
Requests for appeals of adverse credentialing/re-credentialing decisions of the NCC should include an
explanation of the reasons the provider/participating provider believes the NCC reached a decision to be
in error and include supporting documentation. The PAC will review the explanation provided, the
information previously reviewed by the NCC, and any additional information determined to be relevant.
The PAC may request additional information from the provider/participating provider in order to make a
determination or decision. The PAC will support, modify, or overturn the decision of the NCC. Written
notification of the PAC’s decision, an explanation of the decision, and any appeal and/or fair hearing
rights available for adverse decisions, will be sent to the provider/participating provider within 14 business
days after the PAC’s record is complete.
7.01 Professional Review Activities/Fair Hearing Process
Individual providers/participating providers, where required by applicable law, may request a second level
of appeal/a fair hearing when the PAC denies credentialing or re-credentialing, issues a sanction, or
recommends termination of participation status of the provider from the Beacon provider network, where
such denial, sanction, or recommendation is based on quality of care issues and/or issues related to
professional competence or professional conduct.
Included in written notification of a PAC adverse decision based on quality of care issues and/or issues
related to professional competency or professional conduct, will be an explanation of the decision,
whether or not fair hearing rights are available to the provider/participating provider, and an explanation of
fair hearing procedures if applicable.
Requests for a fair hearing must be submitted to Beacon within 30 calendar days of the date of the PAC
notification of adverse decision to the provider/participating provider. While Beacon will make reasonable
efforts to coordinate the date and time of fair hearings requested with the involved provider/participating
provider, should Beacon and the involved provider/participating provider be unable to come to agreement
on the date and time of the requested fair hearing Beacon will identify the date, time and location for the
fair hearing, which date shall be within the 90 calendar day period following request for the fair hearing or
within the timeframe required by applicable State regulations.
Beacon will identify peer reviewers who will participate as the fair hearing panel. Every effort will be made
to include a representative of the discipline of the provider/participating provider requesting the fair
hearing on the panel. Members of the fair hearing panel will not have participated in the prior adverse
decisions of the PAC or NCC, and will be asked to represent that they do not have an economic interest
adverse to the provider/participating provider. One member of the fair hearing panel will be selected to act
as the hearing officer and will preside over the fair hearing.
Beacon and the provider/participating provider each have the right to legal representation if the
provider/participating provider is eligible for a fair hearing. The provider/participating provider will receive
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the written recommendation from the panel within 15 business days after the fair hearing. The fair hearing
process as set forth above is subject to applicable state and/or federal laws and/or regulations.
8. OFFICE PROCEDURES
8.01 Member Rights and Responsibilities
The following is the list of Beacon’s Member Rights & Responsibilities.
Beacon members have the right to:
Be treated with respect and dignity.
Have your personal information be private based on our policies and U.S. law.
Get information that is easy to understand and in a language you know.
Know about the way your health benefits work.
Know about our company, services, and provider network.
Know about your rights and responsibilities.
Tell us what you think your rights and responsibilities should be.
Get care when you need it.
Talk with your provider about your treatment options - regardless of cost or benefit coverage.
Decide with your provider what is the best plan for your care.
Refuse treatment if you want, as allowed by the law.
Get care without fear of any unnecessary restraint or seclusion.
Decide who will make medical decisions for you if you cannot make them.
Have someone speak for you when you talk with Beacon.
See or change your medical record, as allowed by our policy and the law.
Understand your bill.
Expect reasonable adjustments for disabilities as allowed by law.
Request a second opinion.
Tell us your complaints.
Appeal if you disagree with a decision made by Beacon about your care.
Be treated fairly - even if you tell us your thoughts or appeal.
Beacon members have the role to:
Give us and your providers the information needed to help you get the best possible care.
Follow the health care plan that you agreed on with your health care provider.
Talk to your provider before changing your treatment plan.
Understand your health problems as well as you can. Work with your health care providers to
make a treatment plan that you all agree on.
Read all information about your health benefits and ask for help if you have questions.
Follow all health plan rules and policies.
Choose an In-Network primary care physician, also called a PCP, if your health plan requires it.
Tell your health plan or Beacon of any changes to your name, address or insurance.
Contact your provider when needed, or call 911 if you have any emergency.
Beacon’s Member Rights and Responsibilities Statement is available as a one -page pdf in English and
Spanish for download from the website. Providers and practitioners are encouraged to ensure your
practice supports the Rights and Responsibilities of our Members.
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8.02 Confidentiality, Privacy, and Security of Identifiable Health Information
Providers/participating providers are:
Expected to comply with applicable federal and state privacy, confidentiality, and security laws,
rules, and/or regulations, including without limitation the federal Health Insurance Portability and
Accountability Act of 1996 (HIPAA), 42 C.F.R. Part 2, Health Information Technology for
Economic and Clinical Health Act (HITECH Act), and the rules and regulations promulgated
thereunder.
Responsible for meeting their obligations under these laws, rules, and regulations, by
implementing such activities as monitoring changes in the laws, implementing appropriate
mitigation and corrective actions, and timely distribution of notices to patients(members),
government agencies and the media when applicable.
Providers are also responsible for obtaining from members written release of authorizations to share
Substance Use Disorder PHI for treatment, payment, or healthcare operations purposes with
Beacon. The release should be retained on file.
With the enactment of the federal HIPAA and HITECH Act, members or their legal guardian give consent
for the release of information regarding treatment, payment, and health care operations at the signup for
health insurance. Treatment, payment, and health care operations involve many different activities,
including but not limited to:
Submission and payment of claims
Seeking authorization for extended treatment
Quality Improvement initiatives, including information regarding the diagnosis, treatment, and
condition of members to ensure compliance with contractual obligations
Member information reviews in the context of management audits, financial audits, or program
evaluations
Chart reviews to monitor the provision of clinical services and ensure that authorization criteria
are applied appropriately
In the event that Beacon receives a complaint or becomes aware of a potential violation or breach of an
obligation to secure or protect member information, Beacon will notify the provider/participating provider
utilizing the general complaint process, and request that the provider/participating provider respond to the
allegation and implement corrective action when appropriate. Participating providers must respond to
such requests and implement corrective action as indicated in communications from Beacon.
Providers/participating providers and their business associates interacting with Beacon staff should make
every effort to keep protected health information (PHI) and personally identifiable information (PII) secure.
If provider/participating provider does not use email encryption, Beacon recommends sending protected
health information to Beacon through an inquiry in ProviderConnect or by secure fax.
8.03 Appointment and Availability Standards
Participating providers are expected to maintain established office/service hours and access to
appointments with standards established by Beacon and/or as may be required by a given client of
Beacon and/or specific government sponsored health benefit program. Beacon’s provider contract
requires that the hours of operation of all of our network providers are convenient to the population served
and do not discriminate against members (e.g., hours of operation may be no less than those for
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commercially-insured or public fee-for-service-insured individuals), and that services are available twenty-
four hours a day, seven days a week, when medically necessary.
Except as otherwise required by a specific client and/or government sponsored health benefit program for
providers participating in networks available to their respective members and/or as delineated in the
provider agreement, the following are standards of availability for appointments which participating
providers are required to maintain:
Emergency:
In an emergency situation, the member should be seen in person immediately or
referred to appropriate emergency service providers. Participating providers who
do not maintain 24-hour coverage must maintain a system for referring members
to a source of emergency assistance during non-business hours. The preferred
methods are through a live answering service or an on-call pager system.
However, participating providers may elect to maintain a reliable recorded
answering machine system through which members experiencing an emergency
are given clear instructions about how to access immediate assistance after
hours.
Emergent:
In an emergent situation, the member should be seen within six (6) hours of the
request for an appointment or referred to appropriate emergency service
providers.
Urgent:
In an urgent situation, the member must be offered the opportunity to be seen
within 48 hours of a request for an appointment.
Routine:
In a routine situation, a member must be offered the opportunity to be seen
within 14 calendar days or 10 business days of a request for an appointment.
Routine Follow-
Up Office-Visit
(non-prescriber)
In a routine follow-up situation, a member should be seen within 30 business
days of initial visit.
Routine Follow-
Up Office-Visit
(prescriber)
In a routine follow-up situation, a member should be seen within 90 business
days of initial visit.
8.04 Out-of-Office Coverage
Participating providers should:
Contact their regional provider relations team via email located under ‘Contact Information’ on the
‘Beacon Health Options Providers’ section of the website or the Beacon National Provider
Services Line at 800-397-1630 during normal business hours Mon. through Fri., 8 a.m. to 8 p.m.
ET to inform Beacon of any unavailability or absence
Submit the Beacon Leave of Absence/Out-of-Office Notification Form, located on the ‘Beacon
Health Options Providers’ section of the website, to Beacon National Network Operations at the
address below and advise of coverage arrangements in advance of vacation, sabbatical, illness,
maternity leave (where applicable), and/or any other situation when participating provider is
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unable to continue to treat Beacon members in active treatment. Such advance written notice
should include: participating provider’s name, licensure, practice locations affected, the reason for
unavailability or absence and date range of unavailability or absence. Upon receipt of such
advance notice, the participating provider’s status in Beacon’s systems is changed to ‘inactive.’
Mail to:
Beacon Health Options, Inc.
P.O. Box 989
Latham, NY 12110
OR
Fax to: 866-612-7795
Upon return, participating providers should contact the Beacon National Provider Services Line at 800-
397-1630, Mon. through Fri., 8 a.m. to 8 p.m. ET and should notify Beacon’s National Network Operations
at the address above in writing. Failure to contact Beacon within 30 days of return may result in referral,
utilization management, and claims processing delays due to the ‘inactive’ status placed in Beacon’s
systems. Failure to respond to communications from Beacon related to ‘inactive’ or out-of-office versus
‘active’ status in Beacon’s systems within the time period provided for in such communications may result
in termination of participation in Beacon’s provider networks.
8.05 Termination and Leave of Absence
If a participating provider remains on inactive status for longer than six months, a reminder is sent
informing the provider of the expiration date and the disenrollment process for failure to respond to said
notice.
8.06 Catastrophic Event
In the event that the carrier or provider is unable to meet the regulatory deadlines due to a catastrophic
event, then the entity must notify the plan and Beacon within five days of the event. Within 10 days after
return to normal business operations, the entity must provide a certification in the form of a sworn affidavit
that identifies the nature of the event, and the length of interruption of network status, claims submission
or other administrative impact.
8.07 Requests for Additional Information
To maintain in-network status, participating providers must furnish Beacon with any requested
documentation or information promptly. Failure to do so may result in the participating provider’s status
being changed from active to inactive. Inactive providers are ineligible to receive referrals or
reimbursement as participating providers for services rendered to members of Beacon’s clients and/or
payors.
9. SERVICES TO MEMBERS
Pursuant to the terms of the provider agreement, participating providers are contracted and credentialed
to provide identified covered services to members. Covered services should be rendered in:
The same manner as services rendered to other patients
Accordance with accepted medical standards and all applicable state and/or federal laws, rules,
and/or regulations
A quality and cost-effective manner
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Participating providers should note that coverage for behavioral health services and any limitations and/or
exclusions as well any pre-authorization and/or certification requirements for non-emergency services
vary by benefit plan.
Participating providers must:
Verify member eligibility and benefits using Beacon’s provider portal prior to rendering non-
emergency services as possession of a member identification card does not guarantee that the
member is eligible for benefits.
Note: Member eligibility information on Beacon’s provider portal is updated every night. Eligibility
information obtained by phone is accurate as of the day and time it is provided by Beacon.
Beacon cannot anticipate and is not responsible for retroactive changes or disenrollments
reported at a later date. Beacon recommends that providers check eligibility frequently.
Document other or third party health benefit coverage for members (claims must be submitted to
the primary initially)
Preauthorize or certify care where required in Beacon’s policies and procedures or the applicable
member benefit plan, prior to rendering non-emergency services using Beacon’s provider portal
Collect member expenses from the member prior to, at the time of, or subsequent to services
being rendered
Provide continuous care for members or arrange for on-call coverage by other Beacon
participating providers and communicate with members accordingly
Adhere to the accessibility and availability standards established by Beacon
Provide equal treatment to patients in a non-discriminatory manner, regardless of source of
payment or coverage type or product
Update demographic, office, and/or participating provider profile information promptly and in
advance of changes using ProviderConnect
Notify Beacon of potential inpatient discharge problems
Advise members in writing of financial responsibility regarding services that are not covered, prior
to rendering such service
Cooperate with Beacon in coordinating continued care through alternative agencies, other
vendors, or community resources when benefits end
Notify Beacon of members who may be candidates for potential Care Management
Coordinate care with a member’s other health/medical care provider(s), either behavioral and/or
medical providers who are treating the same or related (co-morbid) conditions
Screen, evaluate, and treat (as medically appropriate), any behavioral health problem.
Refer members to other participating providers when alternative or different mental health or
substance use services are required
Submit claims on behalf of members
Upon written request by Beacon or third party payors, submit copies of member treatment
records without charge (unless otherwise expressly provided for in the provider agreement)
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Make resources available to members who require culturally, linguistically, and/or disability
competent care, such as, but not limited to, disability and language lines
9.01 Emergency Services
In the event of an emergency admission, participating providers should notify Beacon of the date of
admission as soon as reasonably practical and in any event within 48 hours or within such alternative
period of time specified in the provider agreement and/or state regulations. Retrospective review of such
admissions and associated services is subject to the terms of the member’s benefit plan.
Emergency services that are necessary to screen and stabilize a member are authorized without prior
approval when:
A prudent layperson, acting reasonably, believes that an emergency behavioral health condition
exists
An authorized representative, acting on behalf of Beacon, has authorized the provision of
emergency services
As otherwise required under applicable law
Beacon shall at all times authorize an emergency psychiatric evaluation as per the member’s benefit plan.
9.02 Referrals
Participating providers may receive referrals from several sources, including but not limited to:
Providers and/or other participating providers
Self-referral of members;
From Beacon
Through an EAP
Participating providers needing to refer a member for other or additional services should contact Beacon
to identify what are covered services under the member’s benefit plan and any limitations, exclusions
and/or notice, pre-authorization, or certification or notification requirements under their benefit plan. When
possible, Beacon will seek to refer members to participating providers in the Beacon network.
9.03 EAP Transition to Health Plan Benefits
For those members participating in an EAP administered by Beacon and who may schedule and/or be
referred for appointments for behavioral health services by network providers under their benefit plan,
participating providers must be sure to obtain pre-authorization or certification as may be required under
the member’s benefit plan. Questions regarding what are covered services under the member’s benefit
plan and associated member expenses for covered services should be directed to Beacon by viewing a
member’s benefits on the ‘Benefit’ tab in ProviderConnect.
9.04 Coordination with Primary Care/Treating Providers
As part of care coordination activities, participating providers should identify all providers/participating
providers involved in the medical and/or behavioral health care and treatment of a member. Subject to
any required consent or authorization from the member, participating providers should coordinate the
delivery of care to the member with these providers/participating providers. All coordination, including
PCP coordination, should be documented accordingly in the member treatment record. Beacon consent
forms are available through the website.
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Tips to Improve Coordination of Care
1. Request a release of information from the member to coordinate with his/her medical providers.
Use motivational interviewing techniques to encourage information sharing across providers.
a. Educate the member that care coordination improves patient safety and can lead to
improved treatment outcomes. Explain in detail what will be shared and why.
b. Discuss any concerns about care coordination with the member. Encourage questions
and provide adequate time for discussion.
2. Use a standard form to share information. You can use your own or one of the two versions
available for free on Beacon’s website: https://www.beaconhealthoptions.com/providers/forms-
and-resources/.
a. Authorization for Behavioral Health Provider and Primary Care Provider to Share
Confidential Information Form
b. Primary Care Provider Behavioral Health Communication Form
3. Follow a standard process for sharing and requesting information with the member’s medical
provider(s).
a. Call the PCP office and ask the office manager or receptionist how best to communicate
and share information. Discuss a protocol for any urgent medical needs.
b. Routinely communicate with medical providers at specific points in treatment, such as
when treatment begins, when there are changes in the member’s status, or upon
discharge.
4. Ensure that this coordination of care is documented in the member’s medical record. Audit your
own records for compliance with your policies and procedures.
5. Ensure that your intake paperwork/process includes medical history.
6. Keep the member in the communication loop, as clinically appropriate. Provide ongoing updates
on communication between you and other providers.
9.05 Continuation following Provider Agreement Expiration or Termination
Non-renewal and termination of the provider agreement is the process by which the provider agreement
is not renewed at the end of the identified period of time and accordingly ends by its own terms, or the
provider agreement is terminated as provided for in the terms of the provider agreement.
All notices of non-renewal and/or termination of the provider agreement should be in writing and in
accordance with the applicable terms of the provider agreement.
If a participating provider chooses to resign from the network and voluntarily surrender participation
status, the participating provider must send Beacon written notice of such request and/or notice of
termination of the provider agreement pursuant to the “without cause” termination provisions of the
provider agreement (if any). Beacon will send the participating provider written acknowledgement of
receipt of the participating provider’s written request/notice and confirmation of the effective date of
disenrollment/termination consistent with the provisions of the provider agreement. Providers who resign
from network or voluntarily/involuntarily terminate the provider agreement are not eligible for re-
application for six months following the effective date of disenrollment/termination. Exceptions to the six-
month timeframe may be considered in certain situations.
The effective date of non-renewal or termination of the provider agreement is that date:
Identified in the notice of non-renewal or termination of the provider agreement and consistent
with the end of the specific notice period
Mutually agreed upon in writing by the participating provider and Beacon
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On or before the effective date of non-renewal or any termination of the provider agreement, participating
providers must provide Beacon with a list of members for whom the participating provider has rendered
services in the six-month period prior to the effective date of non-renewal or any termination of the
provider agreement.
Participating providers must continue to provide covered services to members following the non-renewal
or termination of the provider agreement pursuant to the terms of the provider agreement and for such
time period(s) as are set out in the provider agreement or as required by government regulations.
Payment for such covered services rendered to members following non-renewal or termination will be at
the rates in the provider agreement.
9.06 Certain Regulatory Requirements
Provider agreements include provisions requiring participating providers to comply with all applicable
state and/or federal laws, rules and/or regulations, including without limitation those related to the
provision of mental health and/or substance use disorder services (e.g., required licensure/certification,
workplace standards, non-discrimination, etc.); child or elder abuse; and duty-to-warn or obligation to
report certain types of disclosures by patients; and those related to fraud, waste, and abuse. It is the
responsibility of providers and participating providers to understand and comply with the professional and
legal requirements within the state(s) in which providers/participating providers practice and/or render
services.
By way of example, the Americans with Disabilities Act of 1990, as amended (ADA) contains provisions
regarding services to certain individuals identified as covered under the ADA. Participating providers are
encouraged to adapt services and their offices/locations to meet the special needs of members.
9.07 Fraud, Waste, and Abuse
Beacon interacts with employees, clients, vendors, providers/participating providers, and members using
standard clinical and business ethics seeking to establish a culture that promotes the prevention,
detection, and resolution of possible violations of laws and unethical conduct. In support of this, Beacon’s
compliance and anti-fraud plan was established to prevent and detect fraud, waste, or abuse in the
behavioral health system through effective communication, training, review, and investigation. The plan,
which includes Beacon’s code of conduct, is intended to be a systematic process aimed at monitoring of
operations, subcontractors, and providers/participating providers’ compliance with applicable laws,
regulations, and contractual obligations, as appropriate. Participating providers are required to comply
with provisions of Beacon’s code of conduct where applicable, including without limitation cooperation
with claims investigations, payment reviews, benefit plan oversight and monitoring activities, government
agency audits and reviews, and participation in training and education. Beacon’s code of conduct is
accessible on the website. If Beacon identifies that fraud, waste, or abuse has occurred based on
information, data, or facts, Beacon must immediately notify relevant state and federal program integrity
agencies following the completion of ordinary due diligence regarding a suspected fraud, waste, or abuse
case.
Examples of provider fraud, waste, and abuse include altered medical records, patterns for billing that
include billing for services not provided, up-coding, or bundling and unbundling, or medically unnecessary
care. This list is not inclusive of all examples of potential provider fraud.
Examples of member fraud, waste, and abuse include under/unreported income, household membership
(spouse/absent parent), out-of-state residence, third party liability, or narcotic use/sales/distribution. This
list is not inclusive of all examples of potential member fraud.
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10. PARTICIPATING PROVIDER COMPLAINTS,
GRIEVANCES, AND APPEALS
The Beacon complaint, grievance, and appeal processes provide an effective method and dependable
problem resolution procedure for the informal resolution of participating provider complaints, issues,
concerns, or disputes that may arise related to the credentialing/re-credentialing process, medical
necessity adverse determinations, administrative denials, claims processing, and payment or denial of
claims, and otherwise related to the provider agreement.
Information about the process for appeals related to credentialing and/or re-credentialing decisions is set
out in the appeals section of this handbook.
Information about the process for appeals of adverse determinations is set out in the appeals section of
this handbook.
10.01 Complaints Regarding the Provider Agreement
Initial participating provider complaints regarding the terms of the provider agreement and/or performance
by Beacon or the participating provider under the provider agreement should be submitted in writing to
the local Beacon Engagement Center or to Beacon’s Provider Relations Department at the address
referenced in the Contacts section of this handbook within ten business days of the event that gave rise
to the complaint or within ten business days from the time the participating provider should have
reasonably first become aware of the event. Correspondence should include all documentation in support
of the complaint and should provide, at a minimum:
Reference to the specific term or provision in the provider agreement in dispute (It is helpful if the
participating provider attaches a copy of the page or pages with the specific term or provision in
dispute.)
A detailed description of the nature of the complaint and what action or inaction allegedly is not
consistent with or contrary to provision in the provider agreement
The specific remedy requested for resolution.
Beacon will review the documentation, investigate the concern, and respond in writing to the participating
provider within 30 business days of receipt of the complaint and requested documentation.
If the participating provider is not satisfied with the response from Beacon to the participating provider’s
initial complaint regarding the terms of the provider agreement and/or performance by Beacon or the
participating provider under the provider agreement, the participating provider may be file a second level
complaint within 10 business days of receipt of Beacon’s response to the participating provider’s initial
complaint, or in the absence of a response to the participating provider’s initial complaint, within 35
business days of submission of the initial complaint, to the local Beacon Engagement Center or Beacon
Provider Relations Department at the address referenced in the Contacts section of this handbook. The
written second level complaint must contain, at a minimum, the same information required in the initial
complaint as well as any additional information pertinent to the complaint. Beacon will review the
documentation, investigate the concern, and provide a final written response to the participating provider
within 30 business days of receipt of the second level complaint and requested documentation.
10.02 General Complaints and Grievances
Participating provider complaints regarding issues other than those related to the terms of the provider
agreement and/or performance under the provider agreement (e.g., service complaints, complaints about
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Beacon’s policies and procedures or the policies and procedures applicable to a specific client benefit
plan or government-sponsored health benefit program
3
) should be directed to the Beacon National
Provider Services Line at 800-397-1630, Mon. through Fri., between 8 a.m. and 8 p.m. ET or in writing to:
Beacon Health Options, Inc.
Attn: Provider Complaint Department
P.O. Box 989
Latham, NY 12110
Beacon will acknowledge receipt of participating provider complaints verbally or in writing, and thereafter
will investigate and attempt to reach a satisfactory resolution of the complaint within 30 calendar days of
receipt of the complaint. A one-time extension of 15 calendar days can be taken by Beacon when a
resolution cannot be reached within the above noted 30 calendar day timeframe and the extension is
solely for the benefit of a member. Beacon will notify the participating provider verbally or in writing of the
resolution to the complaint.
11. CLAIMS PROCEDURES AND E-COMMERCE INITIATIVE
11.01 E-Commerce Initiative
Beacon maintains claims processing procedures designed to comply with the requirements of client
plans, government-sponsored health benefit programs, and applicable state and/or laws, rules, and/or
regulations.
Providers in the Beacon network are strongly recommended to electronically submit all claims.
To electronically submit claims, Beacon’s participating providers are strongly encouraged to use one of
the electronic claims resources detailed further in the section titled “Electronic Resources.” These
resources will expedite claims processing and assist participating providers to conduct certain claim
submission and other routine transactions. Electronic claim submission is also accepted through
clearinghouses. When using the services of a clearinghouse, providers must reference Beacon’s Payer
ID, BEACON963116116, to ensure Beacon receives those claims. Each clearinghouse may have a
payer list that provides an alternative value specific to Beacon, the value published on their website can
also be used.
11.02 Member Expenses
Member expenses due from the member for covered services are determined by the member’s benefit
plan. Detailed information about most of the amounts of member expenses due for inpatient, outpatient or
emergency covered services can be obtained by viewing a member’s benefits on the ‘Benefit’ tab in
ProviderConnect. Participating providers are encouraged to contact Beacon’s Customer Service at the
member’s toll-free number for questions regarding member expenses.
It is the responsibility of the participating provider to collect member expenses due to the participating
provider for covered services rendered.
3
Questions about the policies or procedures applicable to a specific client benefit plan or government sponsored
health benefit program should be directed to the Beacon Customer Service Department by calling the number on
the member’s identification card.
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11.03 Preauthorization, Certification, or Notification
Preauthorization, certification, or notification requirements vary from plan to plan. Participating providers
must determine if such requirements exist prior to the provision of non-emergency services to members.
Information regarding Beacon’s policies and procedures on authorization, certification or notification is
located in the utilization management/review section of this handbook. Participating providers may not
bill, charge or seek reimbursement or a deposit from members for services determined not to be
medically necessary.
Providers/participating providers may verify member eligibility, submit and review authorization/
certification requests, and view authorizations/certifications through ProviderConnect on the website.
11.04 No Balance Billing
Participating providers may not balance bill members for covered services rendered. This means that the
participating provider may not bill, charge or seek reimbursement or a deposit, from the member for
covered services except for applicable member expenses, and non-covered services. Participating
providers are required to comply with provisions of Beacon’s code of conduct where applicable, including,
without limitation, cooperation with claims and billing procedures and participation in training and
education. Balance billing education is provided by Beacon as included in quarterly Fraud, Waste, and
Abuse provider training. It is the provider’s responsibility to check benefits prior to beginning treatment of
the member, to obtain appropriate authorization to provide services, if applicable, and to follow the
procedures set forth in this Handbook.
11.05 Claim Submission Guidelines
Unless otherwise identified in the provider agreement, participating providers must file or submit claims
within 90 calendar days from the date of service or the date of discharge for inpatient admission, or where
applicable from date of determination by the primary payer. Claims after the above noted 90-day time
period after the date of service may be denied due to lack of timely filing. Claims must match the
authorization or certification or notification applicable to covered services for which the claim applies to
avoid potential delays in processing.
Participating providers should not submit claims in their name for services that were provided by a
physician’s assistant, nurse practitioner, psychological assistant, intern or another clinician. In facility or
program settings, supervising clinicians should not submit claims in their name for services that were
provided by a resident, intern or psychological assistant.
Separate claim forms must be submitted for each member for whom the participating provider bills and it
must contain all of the required data elements. Each billing line should be limited to one date of service
and one procedure code.
When billing for CPT codes that include timed services in the code description (e.g., 90832, 90833,
90834, 90836, 90837, 90838, 90839, and appropriate Evaluation and Management codes, the actual time
spent must clearly be documented within the member’s treatment record. This time should be
documented indicating a session’s start and stop times (e.g., 9:00-9:50).
Participating providers should submit claims consistent with national and industry standards. To ensure
adherence to these standards, Beacon relies on claims edits and investigative analysis processes to
identify claims that are not in accordance to national and industry standards and therefore were paid in
error. The claims edits and investigative analysis processes include CMS’s National Correct Coding
Initiative (NCCI), which consists of:
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Procedure-to-Procedure edits that define pairs of HCPCS/CPT codes that should not be reported
together.
Medically Unlikely Edits (MUE) or units-of-service edits. This component defines for each
HCPCS/CPT code the number of units of service that is unlikely to be correct and therefore
needs to be supported by medical records.
Other Edits for Improperly Coded Claims – regulatory or level of care requirements for correct
coding.
Examples of claims edits can include but are not limited to the following:
Invalid procedure and/or diagnosis codes
Invalid code for place of service
Invalid or inappropriate modifier for a code
State-specific edits to support Medicaid requirements
Diagnosis codes that do not support the procedure
Add-on codes reported without a primary procedure code
Charges not supported by documentation based on review of medical records
Claims from suspected fraudulent activities of providers and members that warrant additional
review and consideration
Services provided by a sanctioned provider or provider whose license has been revoked or
restricted
Incorrect fee schedule applied
Duplicate claims paid in error
No authorization on file for a service that requires prior authorization
Claims for covered services rendered to members should be submitted electronically using one of the
electronic claims resources detailed further in the section titled “Electronic Resources.”
Note: If a participating provider uses a clearinghouse to electronically submit claims, please provide the
clearinghouse with Beacon’s payer id, BEACON963116116.
All billings by the participating provider are considered final unless adjustments or a request for review is
received by Beacon within the time period identified in the provider agreement, or if no time period is
identified in the provider agreement within 60 calendar days from the date indicated on the Explanation of
Benefits (EOB). Payment for covered services is based upon authorization, certification, or notification (as
applicable), coverage under the member’s benefit plan and the member’s eligibility at the time of service.
Note: Client plan or government sponsored health benefit program specific claim submission
requirements are located in the ‘Beacon Health Options Providers’ section of the website under ‘Network-
Specific.’
The individual provider is ultimately responsible for the accuracy and valid reporting of all claims
submitted for payment. A provider using the services of a billing agency must ensure through legal
contract (a copy of which must be made available to Beacon upon request) the responsibility of a billing
service to report claim information as directed by the provider in compliance with all policies stated by
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Beacon. It is also the provider’s responsibility to submit claims timely in accordance with the terms in the
Provider Agreement.
11.06 Required Claim Elements
Claims for covered services rendered to members should be submitted using UB-04 or CMS-1500 forms,
or their respective electronic equivalent or successor forms, with all applicable fields completed and all
elements/information required by Beacon included. Tip sheets containing Beacon’s required claim fields
to make a clean claim for the UB04 and CMS-1500 are located on the handbook page of the website.
**All data elements noted as required must be provided, but they must also be current and match what
the subscriber’s employer has on file. If the member’s ID on the claim is illegible, or does not match what
the subscriber’s employer has provided, we may not be able to determine the claimant. We strongly
recommend that you obtain a copy of the member’s ID card, and validate that it is current at the time of
each visit.
**There are times when supporting information is required to approve payment; if supporting
documentation is not included, the claim may not be considered clean.
**Claims that are not submitted on a CMS 1500 2012-02 or a UB04 often will not contain the information
we need to consider the claim clean and will cause the claim to reject or take a longer processing time.
Claims submitted on old claim forms may be returned.
**Electronically submitted claims must also be in a HIPAA 5010 compliant format and conform to the
Beacon companion guide to be considered clean.
In addition, the claim should be free from defect or impropriety (including lack of required substantiating
documentation) or circumstance requiring special treatment that prevents timely payment. If additional
information is required, the participating provider will forward information reasonably requested for the
purpose of consideration and in obtaining necessary information relating to coordination of benefits,
subrogation, and verification of coverage, and health status.
Claims submission guidance, including required claim fields to make a clean claim, is available on the
‘Beacon Health Options Providers’ section of the website.
For paper claims, the use of scanning by means of Optical Character Recognition (OCR) technology
allows for a more automated process of capturing information. The following elements are required to
take advantage of this automated process. If the participating provider does not follow these guidelines,
claims may be returned from the scanning vendor:
Use machine print
Use original red claim forms
Use black ink
Print claim data within the defined boxes on the claim form
Use all capital letters
Use a laser printer for best results
Use correction tape for corrections
Submit any notes on 8 ½” x 11” paper
Use an eight-digit date format (e.g., 10212012)
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Use a fixed width font (Courier, for example)
11.07 Requests for Additional Information
To maintain in-network status and upon request by Beacon, or its authorized designee, participating
providers must promptly furnish requested documentation or information related to and/or in support of
claims submitted. Failure to do so may result in a change in network participation status from active to
inactive. Inactive providers are ineligible to receive referrals or payment as a participating provider for
covered services rendered to members.
11.08 Claims Processing
Beacon, or its designee, will process complete and accurate claims submitted by providers/participating
providers for covered services rendered to members in accordance with normal claims processing
policies and procedures, the payment terms included in the provider agreement, and applicable state
and/or federal laws, rules and/or regulations with respect to timeliness of claims processing.
For Participating Providers Located in New York Only: Beacon, when performing claims processing
activities as a delegate of a New York Public Health Law Article 44 licensed managed care organization
and as such acting as a management contractor to such managed care organization(s), has initial
responsibility for determining payment of claims for covered services rendered to members that are
submitted by participating providers contracted with CHCS IPA, Inc. Participating providers contracted
with CHCS IPA, Inc. understand and agree that CHCS IPA, Inc. may act as agent for such participating
providers with regard to the processing of claims by Beacon and further that CHCS IPA, Inc. has the
authority to play an active role in resolving claims processing issues that participating providers
contracted with CHCS IPA, Inc. may have with Beacon (acting as a management contractor for the above
noted New York managed care organizations).
Normal claims processing procedures may include, without limitation, the use of automated systems
which compare claims submitted with diagnosis codes and/or procedure codes and associated billing or
revenue codes. Automated systems may include edits that result in an adjustment of the payment to the
provider/participating provider for covered services or in a request for submission of treatment records.
Participating provider agrees that no payment is due for covered services or claims submitted unless the
covered services are clearly and accurately documented in the treatment record prior to submission of the
claim.
Reimbursement for covered services provided in an inpatient facility, inpatient rehabilitation or residential
setting/level of care will be at the contracted reimbursement rate in effect on the date of admission.
Payment for services rendered to members is impacted by the terms in the provider agreement, the
member’s eligibility at the time of the service, whether the services were covered services, if the services
were medically necessary, compliance with any preauthorization/certification/notification requirements,
member expenses, timely submission of the claim, claims processing procedures, overpayment recovery,
and/or coordination of benefits activities.
Note: Regardless of any provision to the contrary, participating providers acknowledge and agree that the
payment rates in the provider agreement extend and apply to covered services rendered to members of
benefit plans administered in whole or in part by Beacon.
11.09 Provider Summary Vouchers
PSVs or remittance advices are the documents that identify the amount(s) paid and member expenses
due from the member. Providers/participating providers should access PSVs through ProviderConnect or
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request copies of PSVs via facsimile through Beacon’s automated PSV faxback service at 866-409-5958.
Accessing PSVs electronically is a transaction subject to the e-commerce initiative. Additional information
regarding access to PSVs is available at the ‘Provider’ section on the website.
11.10 Coordination of Benefits
Some members may have health benefits coverage from more than one source. In these instances,
benefit coverage is coordinated between primary and secondary payers.
Participating providers should obtain information from members as to whether the member has health
benefits coverage from more than one source, and if so provide this information to Beacon.
Coordination of benefits amongst different sources of coverage (payers) is governed by the terms of the
member’s benefit plan and applicable state and/or federal laws, rules and/or regulations. To the extent
not otherwise required by applicable laws or regulations, participating providers agree that in no event will
payment from primary and secondary payers for covered services rendered to members exceed the rate
specified in the provider agreement.
Participating providers must submit a copy of the EOB through Availity or via mail that includes the
primary payer’s determination when submitting claims to Beacon. The services included in the claim
submitted to Beacon should match the services included in the primary payer EOB.
Authorization, certification or notification requirements under the member’s benefit plan still apply in
coordination of benefits situations.
Note: Some benefit plans require that the member update at designated time periods (e.g., annually)
other health benefit coverage information. Claims may be denied in the event the member fails to provide
the required other coverage updates.
11.11 Overpayment Recovery
Participating providers should routinely review claims and payments in an effort to assure that they code
correctly and have not received any overpayments. Beacon will notify providers and participating
providers of overpayments identified by Beacon, clients and/or government agencies, and/or their
respective designees. Overpayments include, but are not limited to:
Claims paid in error
Claims allowed/paid greater than billed
Inpatient claim charges equal to the allowed amounts
Duplicate payments
Payments made for individuals whose benefit coverage is or was terminated
Payments made for services in excess of applicable benefit limitations
Payments made in excess of amounts due in instances of third party liability and/or coordination
of benefits
Claims submitted contrary to national and industry standards such as the CMS National Correct
Coding Initiative (NCCI) and medically unlikely edits (MUE) described in the Claims Submission
Guidelines
Subject to the terms of the provider agreement and applicable state and/or federal laws and/or
regulations, Beacon or its designee will pursue recovery of overpayments through:
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Adjustment of the claim or claims in question creating a negative balance reflected on the PSV
(claims remittance)
Written notice of the overpayment and request for repayment of the claims identified as overpaid
Failure to respond to any written notice of and/or request for repayment of identified overpayments in the
time period identified in the notice/request is deemed approval and agreement with the overpayment;
thereafter, Beacon will adjust the claim or claims in question creating a negative balance. Any negative
balance created will be offset against future claims payments until the negative balance is zeroed out and
the full amount of the overpayment is recovered. Beacon may use automated processes for claims
adjustments in the overpayment recovery process.
In those instances in which there is an outstanding negative balance as a result of claims adjustments for
overpayments for more than 90 calendar days, Beacon reserves the right to issue a demand for re-
payment. Should a provider/participating provider fail to respond and/or provide amounts demanded
within the 30 calendar days of the date of the demand letter, Beacon will pursue all available legal and
equitable remedies, including without limitation placing the outstanding overpayment amount (negative
balance) into collections.
If the provider/participating provider disagrees with an overpayment recovery and/or request for re-
payment of an overpayment, the provider/participating provider may request review to Beacon in writing
such that the written request for review is received by Beacon on or before the date identified in the notice
of overpayment recovery or request for re-payment of an overpayment. Please attach a copy of your
written demand or request letter to your request for review and include the following information;
provider/participating provider’s name, identification number and contact information, member name, and
number, a clear identification of the disputed items to include the date of service and the reason the
disputed overpayments are being contested.
11.12 Requests for Review
Participating providers may request review of a Beacon claims determination. All requests for review must
be submitted in writing or made telephonically to the address and/or telephone number on the member’s
identification card within 60 calendar days or the time period specified in the provider agreement (if any)
from the date of Beacon’s original claim determination.
Requests for review received beyond the above noted time period will not be reviewed and are
considered ‘expired.’
11.13 Claims Disputes
Participating providers must exhaust all administrative processes concerning unresolved claims disputes
pursuant to the terms of the provider agreement, and more specifically any dispute resolution provisions,
prior to pursuing any legal or equitable action.
11.14 Claims Billing Audits
Beacon reviews and monitors claims and billing practices of providers/participating providers in response
to referrals. Referrals may be received from a variety of sources, including without limitation:
Members
External referrals from state, federal and other regulatory agencies
Internal staff
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Data analysis
Whistleblowers
Beacon also conducts unplanned audits. Beacon conducts the majority of its audits by reviewing records
providers/participating providers either scan or mail to Beacon, but in some instances on-site audits are
performed as well. Record review audits, or discovery audits, entail requesting an initial sample
4
of
records from the provider/participating provider to compare against claims submission records. Following
the review of the initial sample, Beacon may request additional records and pursue a full/comprehensive
audit. Records reviewed may include, but are not limited to, financial, administrative, current and past
staff rosters, and treatment records. For the purposes of Beacon audits, the ‘treatment record’ includes,
but is not limited to, progress notes, medication prescriptions and monitoring, documentation of
counseling sessions, the modalities and frequency of treatment furnished, and results of clinical tests. It
may also include summaries of the diagnosis, functional status, treatment plan, symptoms, prognosis,
and progress to date.
Providers/participating providers must supply copies of requested documents to Beacon within the
required timeframe. The required timeframe will vary based on the number of records requested but will
not normally be less than 10 business days when providers/participating providers are asked to either
scan or mail records to Beacon. For the purpose of on-site audits, providers/participating providers must
make records available to Beacon’s staff during the provider’s audit. Providers/participating providers are
required to sign a form certifying all requested records and documentation were submitted or made
available for the audit. Beacon will not accept additional or missing documentation and/or records once
this form is signed, including for the purposes of a request for appeal. Beacon will not reimburse
providers/participating providers for copying fees related to providing of documents and/or treatment
records requested in the course of a claims billing audit, unless otherwise specifically required by
applicable state or federal law, rule, or regulation.
In the course of an audit, documents and records provided are compared against the claims submitted by
the provider/participating provider. Claims must be supported by adequate documentation of the
treatment and services rendered. Participating providers’ strict adherence to these guidelines is required.
A member’s treatment record must include the following core elements: member name, date of service,
rendering provider signature and/or rendering provider name and credentials, diagnosis code, start and
stop times (e.g., 9:00 to 9:50), time-based CPT codes, and service code to substantiate the billed
services. Documentation must also meet the requirements outlined in the ‘Treatment Record Standards
and Guidelines’ section of this handbook. Beacon coordinates claims billing audits with appropriate
Beacon clinical representatives when necessary. The lack of proper documentation for services rendered
could result in denial of payment, or, if payment has already been issued, a request for refund.
Following completion of review of the documents and records received, Beacon will provide a written
report of the findings to the provider/participating provider. In some instances, such report of the findings
may include a request for additional records.
Beacon has established an audit error rate threshold of 10 percent to determine whether the
provider/participating provider had accurate, complete and timely claim/encounter submissions for the
audit review period. Depending on the audit error rate and the corresponding audit results, Beacon’s
report of findings may include specific requirements for corrective action to be implemented by the
4
Unless otherwise required by a specific client or a government agency, Beacon utilizes the Office of Inspector
General’s (OIG) RAT-STATS tool to select a sample of eligible records.
43
provider/participating provider if the audit identifies improper or unsubstantiated billings. Requirements
may include, but are not limited to:
Education/Training – Beacon may require the provider/participating provider to work with
provider relations to develop an educational/training program addressing the deficiencies
identified. Beacon may provide tools to assist the provider/participating provider in correcting
such deficiencies.
Corrective Action Plan – Beacon may require the provider/participating provider to submit a
corrective action plan identifying steps the provider/participating provider will take to correct all
identified deficiencies. Corrective action plans should include, at a minimum, confirmation of the
provider’s/participating provider’s understanding of the audit findings and agreement to correct
the identified deficiencies within a specific timeframe.
Repayment of Claims – The audit report will specify any overpayments to be paid to Beacon.
The overpayment amount will be based on the deficiency determined in the audit process and/or
the value of the claims identified as billed without accurate or supportive documentation. The
provider/participating provider will be responsible for paying the amount owed, based on
Beacon’s findings within 10 business days, unless the provider/participating provider has an
approved installment payment plan.
Monitoring – Beacon may require monitoring of claims submissions and treatment records in 90-
day increments until compliance is demonstrated. The provider’s/participating provider’s
monitored claims are not submitted for payment until each is reviewed for accuracy and
correctness.
Referral to NCC Reporting/Contract Termination – Beacon’s audit team may decide that the
results of an audit warrant referral to the NCC. If a provider/participating provider reported to the
NCC is not immediately dis-enrolled and is permitted to remain active by accepting a corrective
action and/or recoupment plan, but later fails to follow through, the provider/participating provider
may be re-addressed by the NCC and involuntarily dis-enrolled for breach of contract.
11.15 Appeal
If the participating provider disagrees with an audit report’s findings, the participating provider may
request an appeal of the audit report of findings. All appeals must be submitted in writing and received by
Beacon on or before the due date identified in the report of findings letter. Beacon has no obligation to
consider late-filed appeals.
Appeals must include:
A copy of the audit report of findings letter
The participating provider’s name and identification number
Contact information
Identification of the claims at issue, including the name or names of the members, dates of
service, and an explanation of the reason/basis for the dispute.
Absent extraordinary circumstances, Beacon will not accept or consider documentation and/or records
that were not submitted with the original audit submission.
The participating provider’s appeal will be presented to Beacon’s National Compliance – Corporate SIU
Subcommittee within 45 days of receiving the participating provider’s request for appeal. The
44
subcommittee is comprised of Beacon employees who have not been involved in reaching the prior
findings. The subcommittee will review the participating provider’s appeal documentation, discuss the
facts of the case, as well as any applicable contractual, state or federal statutes. The Beacon staff
member/auditor who completed the participating provider’s audit will present his/her audit findings to the
subcommittee but will not vote on the appeal itself. The subcommittee will uphold, overturn, uphold in-
part, or pend the appeal for more information. Once a vote is taken, it will be documented and
communicated to the participating provider within 10 business days of the subcommittee’s meeting. If
additional time is needed to complete the appeal, Beacon will submit a letter of extension to the
participating provider requesting any additional information required of the participating provider and
estimating a time of completion. If repayments or a corrective action plan (CAP) are required, the
participating provider must submit the required repayments or CAP within 10 business days of receiving
the subcommittee’s findings letter, unless an installment payment plan is approved.
Beacon will take appropriate legal and administrative action in the event a provider/participating provider
fails to supply requested documentation and member records or fails to cooperate with a Beacon
investigation or corrective action plan. Beacon may also seek termination of the provider agreement
and/or actions to recover amounts previously paid on claims involved in the investigation or requests for
records. Beacon will report any suspicion or knowledge of fraud, waste, or abuse to the appropriate
authorities or regulatory agency as required or when appropriate.
11.16 Reporting Fraud, Waste, and Abuse
Providers/participating providers should report fraud, waste, and abuse, or suspicious activity thereof,
such as inappropriate billing practices (e.g., billing for services not rendered or use of CPT codes not
documented in the treatment record). Reports and questions may be made in writing to Beacon at the
address below or by calling the Beacon Ethics Hotline at 888-293-3027.
Beacon Health Options
Attn: Corporate SIU
SIU@beaconhealthoptions.com
12. UTILIZATION MANAGEMENT
The Beacon utilization management program encompasses management of care from the point of entry
through discharge using objective, standardized, and widely-distributed clinical protocols and enhanced
outpatient care management interventions. Specific utilization management activities may apply for high-
cost, highly restrictive levels of care and cases that represent clinical complexity and risk. Participating
providers are required to comply with utilization management policies and procedures and associated
review processes.
Examples of review activities included in Beacon’s utilization management program are determinations of
medical necessity, preauthorization, certification, notification, concurrent review, retrospective review,
care/case management, discharge planning, and coordination of care.
The Beacon utilization management program includes processes to address:
Easy and early access to appropriate treatment
Working collaboratively with participating providers in promoting delivery of quality care according
to accepted best-practice standards
Addressing the needs of special populations, such as children and the elderly
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Identification of common illnesses or trends of illness
Identification of high-risk cases for intensive care management
Screening, education and outreach
Objective, scientifically-based medical necessity criteria and clinical practice guidelines, in the context of
provider or member supplied clinical information, guide the utilization management processes.
All utilization management decisions are based on the approved medical necessity criteria. Additionally,
criteria is applied with consideration to the individual needs of the member and an assessment of the
local delivery system.
1. Individual needs and characteristics of the member include: age, linguistic, or ethnic
factors, co-morbidities and complications, progress of treatment, psychosocial situation,
and home environment.
2. Characteristics of the local delivery system available to the member include aspects such
as availability of alternative levels of care, benefit coverage for the available alternatives,
and ability of local providers to provide all recommended services within the estimated
length of stay.
Prior to beginning a course of outpatient treatment and/or a non-emergency admission,
providers/participating providers must verify member eligibility and obtain authorization or certification
(where applicable). Providers/participating providers are strongly encouraged to verify eligibility and
benefits and submit authorization requests (where applicable) via ProviderConnect.
In order to verify member eligibility, the provider/participating provider will need to have the following
information available:
Patient’s name, date of birth, and member identification number
Insured or covered employee’s name, date of birth, and member identification number
Information about other or additional insurance or health benefit coverage
Based on the most recent data provided by employer/benefit plan sponsor, benefit plan administrator,
and/or where applicable the sponsoring government agency, Beacon will:
Verify member eligibility
Identify benefits and associated member expenses under the member’s benefit plan
Identify the authorization or certification procedures and requirements under the member’s benefit
plan
Note: Verification of eligibility and/or identification of benefits and member expenses are not authorization
or certification or a guarantee of payment.
12.01 New and Emerging Technologies
Beacon recognizes the need for knowledge of emerging technologies to provide access to optimum care
for members. Beacon evaluates these technologies in terms of their overall potential benefits to members
and in some instances recommends these technologies to clients for inclusion in their respective benefit
packages. Examples of new technologies are psychotropic medications or new, approved uses of current
medications, innovative community service programs and new approaches to provision of psychotherapy
and treatment. Beacon has established committees that conduct formal reviews of potential new
46
technologies. The effectiveness of new service technologies will be considered in medical necessity
decisions.
12.02 Treatment Planning
Providers/participating providers must develop individualized treatment plans that utilize assessment
data, address the member’s current problems related to the behavioral health diagnosis, and actively
include the member and significant others, as appropriate, in the treatment planning process. CCMs
review the treatment plans with the providers/participating providers to ensure that they include all
elements required by the provider agreement, applicable government program, and at a minimum:
Specific measurable goals and objectives
Reflect the use of relevant therapies
Show appropriate involvement of pertinent community agencies
Demonstrate discharge planning from the time of admission
Reflect active involvement of the member and significant others as appropriate
Providers/participating providers are expected to document progress toward meeting goals and objectives
in the treatment record and to review and revise treatment plans as appropriate.
12.03 Clinical Review Process
Provider/participating provider cooperation in efforts to review care prospectively is an integral part of
care coordination activities. Subject to the terms of the member’s benefit plan and applicable state and/or
federal laws and/or regulations, providers/participating providers must notify Beacon prior to admitting a
member to any non-emergency level of care. The Mental Health Parity & Addiction Equity Act of 2008
requires that mental health and substance use disorder benefits, provided by group health plans with
more than 50 employees, must be available on an equivalent or better basis to any medical or surgical
benefits. Some benefit plans, but not all, may fall under this guideline and do not require notification or
authorization for standard outpatient services. Others may allow for a designated number of outpatient
sessions without prior-authorization, certification, or notification. Beacon may request clinical information
at various points in treatment to ensure the ongoing need for care and treatment that is appropriate and
effective in improving health outcomes for members.
In all cases, providers/participating providers are encouraged to contact Beacon prior to initiating any
non-emergency treatment to verify member eligibility and to clarify what the authorization or certification
requirements are, if any, for the proposed treatment.
Coverage and payment for services proposed for and/or provided to members for the identification or
treatment of a member’s condition or illness is conditioned upon member eligibility, the benefits covered
under the member’s benefit plan at the time of service, and on the determination of medical necessity of
such services and/or treatment. Overpayments made as a result of a change in eligibility of a member are
subject to recovery (see Overpayment Recovery section).
Subject to verification of eligibility under the member’s benefit plan, upon request for authorization or
certification of services, the CCM gathers the required clinical information from the provider/participating
provider, references the appropriate medical necessity criteria for the services and/or level of care, and
determines whether the services and treatment meets criteria for medical necessity. The CCM may
authorize or certify levels of care and treatment services that are specified as under the member’s benefit
plan (e.g., acute inpatient, residential, partial hospitalization, intensive outpatient, or outpatient).
47
Authorizations or certifications are for a specific number of services/units of services/days and for a
specific time period based on the member’s clinical needs and provider characteristics. Beacon reserves
the right to reject or return authorization requests that are incomplete, lacking in specificity, or incorrectly
filled out. Beacon will provide an explanation of action(s) which must be taken by the provider to resubmit
the request.
Beacon is required by the state, federal government, NCQA and the Utilization Review Accreditation
Commission (URAC) to render utilization review decisions in a timely manner to accommodate the clinical
urgency of a situation. Beacon has adopted the strictest timeframe for all UM decisions to comply with the
various requirements.
Beacon’s internal timeframes for rendering a UM determination and notifying members of such
determination begin at the time of Beacon’s receipt of the request. Note, the maximum timeframes may
vary on a case-by-case basis in accordance with state, federal government, NCQA or URAC
requirements. Refer to the provider portal and network specific sites for specific plan requirements.
Prior to initial determinations of medical necessity, the member’s eligibility status and coverage under a
benefit plan administered by Beacon should be confirmed. If eligibility information is not available in non-
emergency situations, a CCM may complete a screening assessment and pend the
authorization/certification awaiting eligibility verification. CCMs will work with members and
providers/participating providers in situations of emergency, regardless of eligibility status.
If a member’s benefits have been exhausted or the member’s benefit plan does not include coverage for
behavioral health services, the CCM, in coordination with the provider/participating provider as
appropriate, will provide the member with information about available community support services and
programs, such as local or state-funded agencies or facilities, that might provide sliding scale discounts
for continuation in outpatient therapy, or where available under the member’s benefit plan, explore benefit
exchanges with the client plan.
12.04 Retrospective Review
When a provider/participating provider requests a retrospective review for services previously rendered,
Beacon will first determine whether such a retrospective review is available under the member’s benefit
plan and request the reason for the retrospective review (e.g., emergency admission, no presentation of a
Beacon member identification card, etc.). In cases where a retrospective review is available, services will
be reviewed as provided for in this handbook. In cases where a retrospective review is not available
under the member’s benefit plan and/or and where the provider/participating provider fails to follow
administrative process and requirements for authorization, certification, and/or notification, the request for
retrospective review may be administratively denied. Subject to any client, government-sponsored health
benefit program, and/or benefit plan specific requirements, the chart below references the standard
timeframes applicable to the type of review request:
STANDARD DETERMINATION TIME FRAMES
REQUEST TYPE
TIMING
DETERMINATION
Prospective Urgent
Prior to treatment
Within 72 hours
Prospective Non-Urgent
Prior to treatment
Within 15 calendar days (14 for
contracts governed by CMS)
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STANDARD DETERMINATION TIME FRAMES
REQUEST TYPE
TIMING
DETERMINATION
Concurrent Urgent
>24 hours of authorization
expiration
Within 24 hours
Concurrent Urgent
<24 hours from authorization
expiration
Within 72 hours
Concurrent Non-Urgent
Prior to authorization term
Reverts to Prospective, so
within 72 hours/15 calendar
days (14 for contracts governed
by CMS)
Retrospective
After services
Within 30 calendar days
Beacon’s procedures for authorization, certification and/or notification apply to services and treatment
proposed and/or previously rendered in instances where the member benefit plan administered by
Beacon is primary and instances where the member benefit plan administered by Beacon is secondary.
Beacon, at times, may administer both primary and secondary benefit plans of a given member. To avoid
possible duplication of the review process in these cases, providers/participating providers should notify
Beacon of all pertinent employer and other insurance information for the member being treated.
Note: Failure to follow authorization, certification, and/or notification requirements, as applicable, may
result in administrative denial/non-certification and require that the member be held harmless from any
financial responsibility for the provider’s/participating provider’s charges.
12.05 Definition of Medical Necessity
Unless otherwise defined in the provider agreement and/or the applicable member benefit plan and/or the
applicable government sponsored health benefit program, Beacon’s reviewers, CCMs, Peer Advisors,
and other individuals involved in Beacon’s utilization management processes use the following definition
of medical necessity or medically necessary treatment in making authorization and/or certification
determinations as may be amended from time to time:
Intended to prevent, diagnose, correct, cure, alleviate or preclude deterioration of a diagnosable
condition (current ICD or DSM) that threatens life, causes pain or suffering, or results in illness or
infirmity
Expected to improve an individual’s condition or level of functioning
Individualized, specific and consistent with symptoms and diagnosis, and not in excess of
patient’s needs
Essential and consistent with nationally accepted standard clinical evidence generally recognized
by mental health or substance abuse care professionals or publications
Reflective of a level of service that is safe, where no equally effective, more conservative and less
costly treatment is available
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Not primarily intended for the convenience of the recipient, caretaker or provider/participating
provider
No more intensive or restrictive than necessary to balance safety, effectiveness, and efficiency
Not a substitute for non-treatment services addressing environmental factors
12.06 Medical Necessity Criteria
Beacon’s Medical Necessity Criteria (MNC), also known as clinical criteria, are reviewed and updated at
least annually to ensure that they reflect the latest developments in serving individuals with behavioral
health diagnoses. Beacon’s Corporate Medical Management Committee (CMMC) adopts, reviews,
revises and approves Medical Necessity Criteria per client and regulatory requirements.
Medical Necessity Criteria varies according to state and/or contractual requirements and member benefit
coverage. To determine the proper Medical Necessity Criteria, use the following as a guide:
1. For all Medicare members, first identify relevant Centers for Medicare and Medicaid (CMS) National
Coverage Determinations (NCD) or Local Coverage Determinations (LCD) Criteria.
2. If no CMS criteria exists for Medicare members and for all non-Medicare members, identify relevant
custom Medical Necessity Criteria.
3. If no custom criteria exists for the applicable level of care and the treatment is substance use
related, the American Society of Addiction Medicine (ASAM) criteria would be appropriate.
* Exception: Substance Use Lab Testing Criteria is in InterQual
®
Behavioral Health Criteria.
4. If the level of care is not substance use related, Change Healthcare’s InterQual
®
Behavioral Health
Criteria would be appropriate.
5. If 1-4 above are not met, Beacon’s National Medical Necessity Criteria would be appropriate.
Beacon has five (5) types of MNC, depending on client or state contractual requirements and lines of
business:
A. Centers for Medicare and Medicaid (CMS) Criteria – National Coverage Determinations (NCD)
and Local Coverage Determinations (LCD) contained in the Medicare Coverage Database
(https://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx).
B. Change Healthcare’s InterQual Behavioral Health Criteria
C. American Society of Addiction Medicine (ASAM) Criteria
D. Custom criteria, including state or client specific levels of care
E. Beacon’s National Medical Necessity Criteria
Network providers are given an opportunity to comment or give advice on development or adoption of
medical necessity criteria and on instructions for applying the criteria. These comments and opinions are
solicited through practitioner participation on committees and through provider requests for review.
Medical Necessity Criteria is available on Beacon’s website via hyperlinks whenever possible and is
available upon request. To order a copy of the ASAM criteria, please go to the following website:
www.asam.org/PatientPlacementCriteria.html. In addition, Beacon disseminates criteria sets via the
website, provider handbook, provider forums, newsletters, and individual training sessions.
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12.07 Clinical Practice Guidelines
Beacon reviews and endorses clinical practice guidelines on a regular basis to support providers in
making evidence-based care treatment decisions on a variety of topics. The most up-to-date, endorsed,
clinical practice guidelines (CPGs) are posted on the Beacon website. Included are those that have been
developed or updated within the past two years and represent the best clinical information we have at this
time. Others clinical practice resources, while not considered current, still contain information that
continues to be clinically relevant. For example, some of the guidelines may recommend specific
treatment interventions without adequately addressing the sufficiency of the evidence to support the
recommendation. Continued use of the guidelines is warranted because resultant positive clinical
contribution outweighs the fact that the summaries of the supporting research may have lacked adequate
transparency related to the process of ranking the studies necessary to meet today’s standards of
guideline development.
CPGs are used in collaboration with providers to help guide appropriate and clinically effective care for a
variety of complex psychiatric conditions. They may also may be referred to by CCMs and Peer Advisors
during reviews.
The Beacon Scientific Review Committee (SRC) reviews and/or updates each guideline at least every two
years. In addition, if the original source of the guideline publishes an update or makes a change, the SRC
will initiate additional review of the guideline prior to the two-year review cycle. Updates/changes are then
presented to Beacon’s Corporate Medical Management Committee (MMC) for final approval.
Additionally, each year, Beacon measures providers' adherence to at least three (3) Clinical Practice
Resources. Beacon has chosen the following two adult-focused and one child-focused Clinical Practice
Resources for 2020 national measurement, unless otherwise required by contract. Beacon will review a
portion of its members’ medical records using the tool posted on the Beacon website. Questions were
developed from the resources.
As Beacon providers, you are expected to ensure your standards of practice align with the endorsed
clinical practice guidelines.
12.08 Beacon’s Care Management System
Members and participating providers may access the Beacon care management system through any of
the following avenues:
24-hour toll-free emergency care/clinical referral line
Direct registration/certification of care through ProviderConnect for participating providers
Direct registration of care through the Interactive Voice Response (IVR) system (in those local
Beacon Engagement Centers where IVR is used)
Direct authorization/certification of all levels of care through referral by a Beacon CCM
Emergency services through freestanding psychiatric hospitals, medical hospitals with psychiatric
units, emergency rooms, or crisis response teams
If a call is received from a member requesting a referral and/or information about participating providers in
the member’s location, CCMs may conduct a brief screening to assess whether there is a need for urgent
or emergent care. Referrals are made to participating providers, taking into account member preferences
such as geographic location, hours of service, cultural or language requirements, ethnicity, type of degree
the participating provider holds and gender. Additionally, the member may require a clinician with a
specialty such as treatment of eating disorders. In all cases, where available, the CCM will assist in
51
arranging care for the member. The name, location, and phone number of at least three participating
providers will be given to the member.
12.09 Clinical Care Manager Reviews
Beacon’s CCMs base reviews on established criteria adopted by Beacon and/or criteria developed by
Beacon. CCMs are trained to match the needs of members to appropriate services, levels of care,
treatment and length of stay, and community supports. This requires careful consideration of the intensity
and severity of clinical data presented, with the goal of quality treatment in the least restrictive
environment. The clinical integrity of the utilization management program seeks to provide that members
who present for care are appropriately monitored and that comprehensive reviews of all levels of care are
provided. Those cases that appear to be outside of best practice guidelines or appear to have
extraordinary treatment needs are referred for specialized reviews. These may include evaluation for
intensive care management, clinical rounds, peer advisor review or more frequent CCM review.
CCMs obtain clinical data from the provider/participating provider or designee relating to the need for care
and treatment planning. The CCM evaluates this information and references applicable medical necessity
criteria to determine medical necessity of the requested level of care or service. Where appropriate, care
is pre-certified for a specific number of services/days for a specific time period at a specific level of care,
based on the needs of the member.
Except where disclosure of certain information is expressly prohibited by or contrary to applicable state or
federal laws or regulations, participating providers must be prepared to provide Beacon with the following
information at the time of the review, as necessary and appropriate:
Demographics
Diagnosis (current DSM or ICD)
Reason for admission/precipitant
Suicidal/homicidal risk, including:
o Ideation
o Plan
o Intent
o Psychotic/Non-Psychotic (e.g., command hallucinations, paranoid delusions)
Substance use disorder history
o Type
o Amount
o Withdrawal symptoms
o Vital signs
o Date(s) of initial use and last use
o Date(s) of periods of sobriety
Other presenting problem/symptomatology description, if applicable
Progress since admission (if concurrent review)
Medical problems
52
o Medical history
o Organic cause of psychiatric symptoms/behaviors
o Medical problems which exacerbate psychiatric or substance use disorder
symptoms/behaviors
Current medications
o Type(s)
o Dosage(s)
o Date(s)
o Duration
o Response
o Provider(s)
Primary care physician (PCP) interface, if applicable
Other behavioral health care provider interface, if applicable
General level of functioning
o Sleep, appetite
o Mental status
o ADLs (Activities of Daily Living)
Psychological stressors and supports
o Socioeconomic
o Family
o Legal
o Social
o Abuse, neglect, domestic violence (as appropriate)
Response to previous treatment
o Previous treatment history, most recent treatment, past treatment failures
o Relapse/recidivism, motivation for treatment
o Indications of compliance with treatment recommendations
Treatment plan
o Estimated length of stay
o Treatment goals
o Specific planned interventions
o Family involvement
o Precautions for specific risk behaviors
o Educational component for regulatory compliance and substance use disorder situations
53
Discharge plan
o Aftercare required upon discharge
o Barriers to discharge
12.10 Inpatient or Higher Levels of Care
All inpatient and alternative level of care programs (this does not include outpatient therapy rendered in a
provider’s/participating provider’s office or outpatient therapy in a clinic or hospital setting) will be subject
to the review requirements described in this section. Prior to non-emergency admission and/or beginning
treatment, the provider/participating provider must contact Beacon:
For notification
To confirm benefits and verify member eligibility
To provide clinical information regarding the member’s condition and proposed treatment
For authorizations or certifications, where required under the member’s benefit plan and in
compliance with state regulations
It is preferred that providers use the ProviderConnect web portal, available 24 hours a day, seven days a
week (excluding scheduled maintenance and unforeseen systems issues), to confirm benefits and
provide notification and clinical information as appropriate. Providers/participating providers can secure
copies of the authorization/certification requests at time of submission for their records. The web portal
can be utilized for concurrent reviews and discharge reviews as well as initial or precertification reviews.
CCMs and/or referral line clinicians are available 24 hours a day, seven days a week, 365 days a year
and can provide assessments, referrals, and conduct authorization or certification reviews if such
processes are unavailable through ProviderConnect.
Where authorization, certification, or notification is required by the member’s benefit plan and unless
otherwise indicated in the provider agreement, providers/participating providers should contact Beacon
within 48 hours of any emergency admission for notification and/or to obtain any required authorization or
certification for continued stay.
If prior to the end of the initial or any subsequent authorization or certification, the provider/participating
provider proposes to continue treatment, the provider/participating provider must contact Beacon by
phone or ProviderConnect for a review and recertification of medical necessity. It is important that this
review process be completed more than 24 hours prior to the end of the current authorization or
certification period.
Continued stay reviews:
Focus on continued severity of symptoms, appropriateness, and intensity of treatment plan,
member progress, and discharge planning
Involve review of treatment records and discussions with the provider/participating provider or
appropriate facility staff, EAP staff, or other behavioral health providers and reference to the
applicable medical necessity criteria
In instances where the continued stay review by a CCM does not meet medical necessity criteria and/or
where questions arise as to elements of a treatment plan or discharge plan, the CCM will forward the
case file to a Peer Advisor for review.
54
Effective January 1, 2017, Medicaid managed care plans (MMCPs) are to comply with New York State
Insurance Law (INSL) Section 4303(k)(4), as provided by section three of Part B of Chapter 71 of 2016.
This section prohibits prior the need for authorization for inpatient substance use disorder (SUD)
treatment when provided in a participating OASAS-certified facility. In addition, it prohibits concurrent
utilization review during the first 14 days of medically necessary inpatient SUD treatment when provided
in a participating OASAS-certified facility, and where the MMCP was notified and received an initial
treatment plan from the provider within 48 hours of admission. The OASAS facility is also required to
provide periodic clinical updates to the MMCP during the stay.
The statute does not guarantee a member 14 days of treatment. After the initial 14 days, utilization review
may be performed for any part of the stay; however, medical necessity denials issued under these
circumstances may only be made in accordance with LOCADTR and the Medicaid Managed Care Model
Contract.
An MMCP may begin utilization review after 48 hours following admission if the initial treatment plan is not
received or if it is not received within the required 48-hour timeframe. Coverage requirements for court
ordered services and requirements for appropriate discharge planning still apply, as per the Medicaid
Managed Care Model Contract. Members are not to be held financially liable for any portion of their
inpatient SUD treatment stay not covered by the MMCP. Out-of-network authorization determinations for
inpatient SUD treatment services may still be made in accordance with the Medicaid Managed Care
Model Contract.
Note: Submission requirements may vary depending on benefit plan; therefore, it is recommended that
the provider/participating provider contact customer service by dialing the toll-free number on the
member’s insurance card to obtain the correct procedure:
Inpatient Treatment Review (ITR) requests for Acute Mental Health or Acute Detox Services are
only accepted via ProviderConnect for some benefit plans
Residential, partial, and intensive outpatient service requests should be completed via
ProviderConnect
Some benefit plans only allow telephonic review if ProviderConnect is not utilized
Some contracts require requests to only be submitted via ProviderConnect
12.11 Discharge Planning
Discharge planning is an integral part of treatment and begins with the initial review. As a member is
transitioned from inpatient and/or higher levels of care, the CCM will review/discuss with the
provider/participating provider the discharge plan for the member. The following information may be
requested and must be documented:
Discharge date
Aftercare date
o Date of first post-discharge appointment (must occur within seven days of discharge)
o With whom (name, credentials)
o Where (level of care, program/facility name)
Other treatment resources to be utilized:
o Types
55
o Frequency
Medications
o Patient/family education regarding purpose and possible side effects
o Medication plan including responsible parties
Support systems
o Familial, occupational and social support systems available to the patient. If key supports are
absent or problematic, how has this been addressed
o Community resources/self-help groups recommended (note purpose)
EAP linkage
o If indicated (e.g., for substance use aftercare, workplace issues, such as Return-to-Work
Conference, enhanced wraparound services) indicate how this will occur
Medical aftercare (if indicated, note plan, including responsible parties)
Family/work community preparation
o Family illness education, work or school coordination, (e.g., EAP and Return-to-Work
Conference) or other preparation done to support successful community reintegration. Note
specific plan, including responsible parties and their understanding of the plan.
12.12 Case Management Services (For select patients who meet high-risk criteria)
As part of the case management program at Beacon, we offer assistance with:
Discharge planning
Assessment and integration of service for ongoing needs
Coordination with behavioral health services
Collaboration with healthcare providers and caregivers
Providing information about what benefits might be available
Medication education and monitoring
Hospitals may be asked for assistance in enrolling patients in case management during inpatient
admissions.
When requested, please:
1. Have the patient complete the authorization form, with help if needed.
2. Send the authorization to Beacon by faxing it to the number on the form.
3. Schedule a discharge appointment within seven days after discharge. If you need help with
getting an appointment within seven days, please contact Beacon.
12.13 Adverse Clinical Determination/Peer Review
If a case does not appear to meet medical necessity criteria at the requested level of care, the CCM
attempts to discuss the member’s needs with the provider/participating provider and to work
collaboratively with the provider/participating provider to find an appropriate alternative level of care. If no
alternative is agreed upon, the CCM cannot deny a request for services. Requests that do not appear to
56
meet medical necessity criteria or present quality of care issues are referred to a peer reviewer for second
level review. It is important to note that only a Psychiatrist and for some levels of care, a doctoral level
clinical psychologist peer reviewer can clinically deny a request for services.
The peer reviewer considers the available information and may elect to conduct a Peer-to-Peer Review,
which involves a direct telephone conversation with the attending or primary participating provider to
discuss the case. Through this communication, the peer reviewer may obtain clinical data that were not
available to the CCM at the time of the review. This collegial clinical discussion allows the peer reviewer
the opportunity to explore alternative treatment plans with the provider/participating provider and to gain
insight into the attending provider’s anticipated goals, interventions and timeframes. The peer reviewer
may request more information from the provider/participating provider to support specific treatment
protocols and ask about treatment alternatives.
When an adverse determination is made, the treating provider (and hospital, if applicable) is notified of
the decision. In urgent care cases, notification will be given telephonically at the time of the determination.
Written notification of an adverse determination is issued to the member, member representative,
practitioner, and facility within decision timeframes.
If an adverse decision is rendered, the provider/participating provider has the right to speak with the peer
reviewer who made the adverse determination by calling Beacon at the toll-free phone number of the
member’s plan. For substance use treatment, and treatment of minors, Beacon follows federal and state
guidelines regarding release of information in determining the distribution of adverse determination
letters.
All written or electronic adverse determination notices include:
a. The specific reason(s) for the determination not to certify
b. A statement that the clinical rationale, criteria, (or copy of the relevant medical necessity
criteria), guidelines, or protocols used to make the decision will be provided, in writing, upon
request
c. The right of the provider/participating provider to request a reconsideration within three
business days of receipt of the notice when a medical necessity denial is issued without a
peer-to-peer conversation having taken place, or when an administrative denial is issued
because of the failure of a provider/participating provider to respond to a request for peer-to-
peer conversation within a specified timeframe
d. Rights to and instructions for initiating an appeal, including the opportunity to request an
expedited appeal if applicable for first level appeals, and information about the appeal
process
e. The right to request an appeal verbally, in writing, or via fax transmission
f. The timeframe for requesting an appeal
g. The opportunity for the member, provider/participating provider to submit, for consideration as
part of the appeals process, written comments, documents, records, and other information
relating to the case
h. Information regarding the appeals process for urgent care including that expedited external
review may occur concurrently
i. The member’s right to bring a civil action under the Employer Retirement Income Security Act
of 1974 (ERISA), when applicable
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12.14 Telehealth
Beacon has adopted several guidelines with recommendations when telehealth is used:
American Psychological Association (APA) Guidelines for the Practice of Telepsychology
American Psychiatric Association (APA) and American Telemedicine Association (ATA) Best
Practice in Videoconferencing-Based Telemental Health
American Academy of Child & Adolescent Psychiatry (AACAP) Telepsychiatry Toolkit
National Association of Social Workers (NASW), Association of Social Work Boards (ASWB),
Council on Social Work Education (CSWE) and Clinical Social Work Association (CSWA)
Standards for Technology in Social Work Practice
Providers/participating providers can reference the Telemental Health Guidelines for decision-making on
the appropriateness of ATA located on under ‘Clinical Practice Guidelines’ on the website. Participating
providers should contact Beacon for benefit coverage prior to providing this service.
12.15 Outpatient Services
Prior to beginning a course of outpatient treatment, providers/participating providers must verify member
eligibility and obtain authorization or certification (where applicable).
For some Plans, members are allowed a specific set of initial therapy sessions without prior authorization.
These sessions, called initial encounters (IEs), must be provided by contracted in-network providers and
are subject to meeting medical necessity criteria.
Beacon’s model is to count the initial IEs to the provider, not member. This means that if the member
changes providers, the count of initial encounters restarts with the new provider. Initial encounters may
also be refreshed when a member has a break in treatment of more than six months. These IEs are not
renewed annually, rather are applied towards each member’s episode of care with a provider. An episode
of care is defined as continuous treatment with no gap greater than six months. A member is considered
new to outpatient treatment if the member has not been in outpatient treatment within the previous six-
month period as a member. Each IE is counted as one regardless of session duration and the total can
be reviewed through our provider portal
Refer to your provider agreement for specific information about procedure and revenue codes that can be
used for billing. Providers will be asked a series of clinical questions to support medical necessity for the
service requested. If sufficient information is provided to support the request, the service will be
authorized. If additional information is needed, the provider will be prompted to contact Beacon via phone
to continue the request for authorization. While Beacon prefers providers to make requests electronically,
Beacon will work with providers who have technical or staffing barriers to requesting authorizations in this
way.
Providers should request authorization or certification for outpatient services electronically through our
provider portal if authorization is needed. If the electronic method is not available, providers/participating
providers should submit a Beacon Outpatient Review or other state-required or approved outpatient
review form (where applicable), or use the toll-free number for a telephonic review where applicable. In
instances where a review does not meet medical necessity criteria and/or where questions arise as to
elements of a treatment plan, the case file may be forwarded to a Peer Advisor for review.
12.16 Appeal of Adverse Determinations
When a member assigns appeal rights in writing to a participating provider, the participating provider may
appeal on behalf of the member adverse determinations (denials) made by Beacon. Participating
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providers must inform the member of adverse determinations and any appeal rights of which the
participating provider is made aware.
Member appeal rights are limited to those available under the member’s benefit plan, and may involve
one or more levels of appeal.
While the number of appeals available is determined by the member’s benefit plan, the type of appeal,
‘administrative’ or ‘clinical’, is based on the nature of the adverse determination. The member’s care
circumstances at the time of the request for appeal determine the category of appeal as urgent, non-
urgent, or retrospective. The member benefit plan and applicable state and/or federal laws and
regulations determine the timing of the appeal as expedited, standard, or retrospective. For example, if a
provider/participating provider files a Level I appeal on behalf of a member in urgent care, the appeal is
processed as an expedited appeal, even if the member is discharged prior to the resolution of the appeal.
Unless otherwise provided for in the member benefit plan, government sponsored health benefit program,
or applicable state or federal law or regulation, the provider/participating provider and/or the member (or
the member’s authorized representative), has the right to file or request:
An initial (Level I) appeal of an adverse determination for up to 180 calendar days from receipt of
notice of the adverse determination. Initial (Level I) appeals may be made verbally, in writing, or
via fax transmission.
A second level (Level II) appeal of an adverse determination for up to 90 calendar days from
receipt of notice of the Level I appeal determination, in those instances where a second level or
Level II appeal is available to the member. Unless otherwise provided for or restricted under the
member benefit plan, government sponsored health benefit program, or applicable state or
federal law or regulation, second level (Level II) appeals may be made verbally, in writing, or via
fax transmission.
Unless otherwise provided for or restricted under the member benefit plan, government sponsored health
benefit program, or applicable state or federal law or regulation, second level (Level II) appeals may be
made verbally, in writing, or via fax transmission.
The member, member’s authorized representative, and/or the provider/participating provider may submit
any information they feel is pertinent to the appeal request and all such information is considered in the
appeals review, whether or not it was available to Beacon’s reviewers during the initial determination.
The date of the request for a Level I or Level II appeal of the adverse determination is considered the
date and time the appeal request is received by Beacon.
When a provider/participating provider, member (or the member’s authorized representative) requests an
appeal of an adverse determination, the provider/participating provider may not bill or charge the member
until all appeals available to the member have been exhausted by the member, and the member agrees
in writing to pay for non-certified services.
Written notice of determinations for all Level I and Level II appeals of adverse determinations will be
made to the member and the provider/participating provider where required by the member benefit plan,
government sponsored health benefit program, and/or applicable state or federal laws or regulations.
Unless otherwise provided for in the member benefit plan, government sponsored health benefit program,
or applicable state or federal law or regulation, the chart below sets out the turn-around-times for
completion of adverse determination appeals conducted by Beacon.
Unless otherwise provided for in the member benefit plan, government sponsored health benefit program,
or applicable state or federal law or regulation, no adverse determination may be appealed to court,
59
arbitration or otherwise unless and until all available Beacon administrative appeals have been utilized
and exhausted. Failure to timely request any available Beacon administrative appeal shall preclude a
provider from challenging an adverse determination in court, arbitration or otherwise.
Standard Turnaround Times for Appeal Completion and Notice by Type of Care Request
5
TYPE OF CARE
REQUEST AT TIME
APPEAL IS FILED
APPEAL TYPE (CLINICAL AND ADMINISTRATIVE)
EXPEDITED
APPEAL
STANDARD APPEAL
(LEVEL I OR II)
RETROSPECTIVE
APPEAL (LEVEL I OR II)
Urgent
Within 72 hours of
receipt of the appeal
request
Notification: Verbal
notice to provider
within one calendar
day of decision;
written notice to the
provider and the
member within the
decision timeframes
N/A
N/A
Non-Urgent
(Standard)
N/A unless provider
indicates that delay
would impact the life
or health of member,
then process as
urgent above
Within 15 calendar
days of the receipt of
the request for appeal
Notification: Written
notice to the provider
and the member within
the decision timeframe
N/A
Retrospective
N/A
N/A
30 calendar days from
receipt of request for
appeal
Notification: Written
notice to provider and
member within decision
timeframe
12.17 Clinical Appeals
Clinical appeal reviews of adverse medical necessity determinations administered by Beacon are
conducted by an Appeal Reviewer in the same profession and/or in a similar specialty as typically
manages the behavioral health condition, procedure or treatment, as deemed appropriate, or a committee
of practitioners having similar qualifications of an appeal reviewer. Clinical appeal reviewers are neither
5
LACK OF INFORMATION – No extensions are allowed for lack of information or for “reasons beyond the control of
Beacon”. If information submitted is incomplete, Beacon has the option of requesting the necessary information;
however, the decision must still be made within the timeframe for making the appeal decision, or making the
decision based on information on hand.
60
the individual who made the original adverse medical necessity determination, nor the subordinate of
such an individual.
Written notice of Level I and Level II clinical appeal determinations upholding the original adverse
determination (or Level I appeal where applicable), in whole or in part, will include:
The principal reason or reasons for the determination
Reference to the medical necessity criteria and/or guidelines used to be made available upon
request
The procedures for initiating the next step in the appeal process, if any
The right of the member and/or the provider/participating provider to submit additional information
in support of the next level of appeal, if any
Where applicable information related to the member’s right to file suit and/or to pursue other
voluntary dispute options as required by ERISA, or provisions as may be required by applicable
laws, regulations or government-sponsored health benefits programs (e.g., Medicare Advantage
or Managed Medicaid)
TYPE OF APPEAL
PROCESS
Level I (Initial)
Standard Appeals
Upon being assigned a case for review of an adverse determination clinical
appeal, an Appeal Reviewer will investigate the substance of the appeal,
including aspects of the clinical care involved, and review of documents,
records, or other information submitted with the request for the Level I
appeal, regardless of whether such information was also submitted or
considered in the original adverse determination and the applicable medical
necessity criteria. The Appeal Reviewer will attempt to contact the
provider/participating provider (or the clinical representative of facility or
program providers/participating providers) directly to conduct a telephonic
review as appropriate. Based on consideration of all pertinent information,
including relevant medical necessity criteria and guidelines, the Appeal
Reviewer will make a determination to reverse (i.e., overturn) the original
adverse determination in whole or part, or to uphold the original adverse
determination.
When an adverse determination clinical appeal review is conducted and
completed telephonically, the Appeal Reviewer will verbally inform the
provider/participating provider of the determination. If the determination is to
reverse the original adverse determination, the Appeal Reviewer will identify
the length of stay, level of care and/or number of service units or sessions
determined to be medically necessary. If the determination is to uphold the
adverse determination, the Appeal Reviewer includes any recommendations
for treatment for which medical necessity could be confirmed and the
procedure for following the next step in the appeals process, if any.
Expedited Appeals
An expedited appeal is a request to review an adverse determination
concerning admission, continued stay, or other behavioral health care
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TYPE OF APPEAL
PROCESS
services for a member who has received urgent services but has not been
discharged from a facility, or when a delay in decision making might
seriously jeopardize the life or health of the member. Only a Level I appeal
can be processed as an expedited appeal. Beacon follows the same
determination procedures outlined above for standard appeals, but issues
the decision and notification for all expedited appeals within 72 hours of the
appeal request. Expedited appeals are conducted by an Appeal Reviewer
not involved in the original adverse determination. Determinations are
communicated by telephone on the same day as the determination, with
written notification sent within the 72-hour timeframe.
Continued coverage is provided for concurrent (expedited) appeals for
inpatient substance use disorder treatment that is provided by an in-network
OASAS-certified facility while the appeal is pending.
Level II
Upon being assigned a case for review of an adverse determination clinical
appeal, an Appeal Reviewer will investigate the substance of the appeal,
including aspects of the clinical care involved, and review of documents,
records, or other information submitted with the request for the Level II
appeal, regardless of whether such information was also submitted or
considered in the original adverse determination or the Level I appeal and
the applicable medical necessity criteria. The Appeal Reviewer will attempt
to contact the provider/participating provider (or the clinical representative of
facility or program providers/participating providers) directly to conduct a
telephonic review as appropriate. Based on consideration of all pertinent
information, including relevant medical necessity criteria and guidelines, the
Appeal Reviewer will make a determination to reverse (i.e., overturn) the
Level I appeal determination in whole or part, or to uphold the original
adverse determination and Level I appeal determination.
This level of clinical appeal involves a review of all pertinent clinical
information by another Peer Reviewer who has not been previously involved
with the adverse determination, or a Level II Appeal Committee, depending
on the member’s benefit plan and what administrative activities have been
delegated to Beacon by the client plan. When a Level II clinical appeal is
conducted by a Level II Appeal Committee, in some circumstances and only
where indicated in the notice of Level I appeal determination the member
may have the right to appear before the Level II Appeal Committee.
Retrospective
A retrospective clinical appeal is one requested after the member has been
discharged from the level of care or treatment service under consideration.
Retrospective clinical appeals of adverse determinations require that the
provider/participating provider send in specific sections of the treatment
record for review. Retrospective clinical appeal determination notices are
issued within the decision timeframe and contain the required information
outlined above under ‘Standard Appeals.’
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TYPE OF APPEAL
PROCESS
Note: There is only one level of retrospective appeal.
12.18 Administrative Appeals
Administrative appeal reviews of adverse determinations (not based on medical necessity) are conducted
by the applicable Beacon Region or Engagement Center Vice President or their designee, or by a Beacon
committee. Administrative appeal reviewers are neither the individual who made the original adverse
determination, nor the subordinate of such an individual.
The types and levels of appeal, as well as decision and notification requirements mirror those described
above for clinical appeals. However, if an administrative denial is in place, it must be resolved before the
clinical request can be processed. The result of this process can include three scenarios:
1. The administrative denial is upheld and the clinical request is never processed
2. The administrative denial is overturned; however, a clinical review is not necessary (e.g., timely
filing waiver approved, corrected claim submitted, etc.)
3. The administrative denial is overturned, the clinical requested is processed, and a clinical
determination is made
12.19 Final Appeal Level
For those benefit plans that provide for a final stage of appeal (clinical or administrative) for the member,
Beacon will cooperate with the requirements of such final stage of appeal and where agreed upon with
the client plan coordinate such final stage of appeal. Final stages of appeal may include reviews by an
arbitration board, benefits committee, external review entities, state agency sponsored external review
processes, and government sponsored health benefits program medical directors, or other review entities
and/or processes. Information about and procedures for such final appeal level, if any, will be included in
notice of appeal determination for the last level of appeal available before final appeals.
13. QUALITY MANAGEMENT/QUALITY IMPROVEMENT
Beacon utilizes a Continuous Quality Improvement (CQI) philosophy through which Beacon directly or
through its authorized designees, monitors and evaluates appropriateness of care and service, identifies
opportunities for improving quality and access, establishes quality improvement initiatives, and monitors
resolution of identified problem areas. This includes monitoring and evaluation of services performed by
Beacon or its designees, as well as behavioral health services rendered by providers and participating
providers.
Beacon’s comprehensive Quality Management Program (QMP) includes Quality Management (QM)
policies and procedures applicable to all participating providers, strategies and major activities performed
to provide for consistency and excellence in the delivery of services, includes a program description, an
annual work plan that includes goals and objectives and specific QM related activities for the upcoming
year and evaluation of the effectiveness of those activities. Participating providers are responsible for
adhering to the QMP and are encouraged to provide comments to Beacon regarding ongoing QMP
activities through direct telephone communications and/or via the Provider website. Beacon requires
each provider to also have its own internal QM and I Program to continually assess quality of care,
access to care, and compliance with medical necessity criteria.
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13.01 Quality Management Committees
The Beacon Executive Oversight Committee (EOC) has ultimate accountability for the oversight and
effectiveness of the QMP. The Corporate Quality Committee (CQC) is the body responsible for
coordinating all corporate level quality management activities and providing oversight, direction, and
consultation to the Region or Engagement Center QM committees as well as specific quality
management programs. Beacon Region or Engagement Center QM committees are responsible for
oversight of the day-to-day operations of their specific QM programs that includes reporting and
communication of their activities and findings to the CQC as well as incorporating activities in their Region
or Engagement Center as part of oversight monitoring responsibilities.
Certain functional areas within Beacon (e.g., claims) maintain quality management programs specific to
the activities and services performed. Quality programs within functional areas are responsible for
coordinating their quality management programs with the overarching QMP by communicating their
findings and activities to the CQC and incorporating activities into their respective QMP.
The CQC reviews and approves the Corporate QM Program Description, QM Program Evaluation, and
integrated QM/UM Work plan at least annually and at the time of any revision. The CQC receives a
quarterly summary of all QM activities included in the work plan.
13.02 Quality Management Program Overview
The Beacon Corporate Quality Management Program (QMP) monitors and evaluates quality across the
entire range of services provided by the company. Along with the trending of quality issues at the Region
or Service Center level, the corporate QMP is intended to ensure that structure and processes are in
place to lead to desired outcomes for members, clients, providers/participating practitioners, and internal
clients.
The scope of the Corporate QMP includes:
a. Clinical services and Utilization Management Programs
b. Supporting improvement of continuity and coordination of care
c. Case Management/Intensive Case Management/Targeted Case Management
d. Quality Improvement Activities (QIAs)/Projects (QIPs)
e. Outcome Measurement and data analysis
f. Network Management/Provider Relations Activities
g. Member Experience Survey
h. Clinical Treatment Record Evaluation
i. Service Availability and Access to Care
j. Practitioner and Provider Quality Performance
k. Annually evaluating member Complaints and Grievances (Appeals) using valid methodology
l. Member Rights and Responsibilities
m. Patient Safety Activities (including identification of safety issues during prospective reviews)
n. Clinical and Administrative Denials and Appeals
o. Performance Indicator development and monitoring activities
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p. Health Literacy and Cultural Competency assurance
q. Compliance with Section 1557, nondiscrimination law in the Affordable Care Act (ACA)
r. Promotion of e-technologies to improve member access and understanding of health benefits
s. Promotion of the use of member self-management tools
t. Screening Programs
u. Complaints and Grievances
Several of the above activities and processes are described in greater detail in other sections of this
handbook.
13.03 Role of Participating Providers
Participating practitioners/providers are informed about the QMP via the Beacon Provider Handbook,
provider newsletters, website information, direct mailings, email provider alerts, seminars and training
programs. Many of these media venues provide network practitioners/providers with the opportunity to be
involved and provide input into the QM and UM Programs. Additional opportunities to be involved include
representation on the National Credentialing and Provider Appeals Sub-Committees as well as on various
committees and sub-committees and/or workgroups at the Regional or Engagement Center level (e.g.,
Credentialing Committee and Clinical Advisory Committees). Involvement includes, but is not limited to:
Providing input into the Beacon medical necessity criteria
Providing peer review and feedback on proposed practice guidelines, clinical quality monitors and
indicators, new technology and any critical issues regarding policies and procedures of Beacon
Reviewing QIAs and making recommendations to improve quality of clinical care and services
Reviewing, evaluating, and making recommendations for the credentialing and re-credentialing of
participating practitioners and organizational providers
Reviewing, evaluating and making recommendations regarding sanctions that result from
participating practitioner and organizational provider performance issues
As part of the QMP, Beacon incorporates principles designed to encourage the provision of care and
treatment in a culturally competent and sensitive manner. These principles include:
Emphasis on the importance of culture and diversity
Assessment of cross-cultural relations
Expansion of cultural knowledge
Consideration of sex and gender identity
Adaptation of services to meet the specific cultural and linguistic needs of members.
Participating providers are reminded to take the cultural background and needs of members into account
when developing treatment plans and/or providing other services.
13.04 Quality Performance Indicator Development and Monitoring Activities
A major component of the quality management process is the identification and monitoring of meaningful
companywide Key Performance Indicators (KPI) that are established, collected, and reported for a small
but critical number of performance measures across Regions or Engagement Centers and all functional
areas of the company. These core performance indicators are selected by functional area leads along
65
with associated goals or benchmarks and are approved by senior management. KPIs are reported to the
Executive Leadership Team (ELT), Corporate Quality Committee (CQC), and/or Corporate Medical
Management Committee (CMMC) at least annually.
All functional areas are responsible for prioritizing their resources to meet or exceed performance goals or
benchmarks established for each indicator. When performance is identified below established goals
and/or trends, a corrective action plan is established to improve performance.
Beacon Regions or Engagement Centers are expected to identify, track, and trend local core
performance indicators relevant to the populations they serve. Client performance reporting requirements
may also be required. In any case, behavioral health care access and service performance is monitored
regularly, including, but not limited to:
Access and availability to behavioral health services
Telephone service factors
Utilization decision timeliness, adherence to medical necessity, and regulatory requirements
Member and provider complaints and grievances
Member and provider satisfaction with program services
Nationally recognized or locally prescribed care outcome indicators such as HEDIS measures
whenever possible
Potential member safety concerns, which are addressed in the Member Safety Program section
of this handbook, include
o Serious reportable events (SREs) as defined by the National Quality Forum (NQF) and
Beacon, and
o Trending Events (TEs)
13.05 Service Availability and Access to Care
Beacon uses a variety of mechanisms to measure member’s access to care with participating
practitioners. Unless other appointment availability standards are required by a specific client or
government-sponsored health benefit program, service availability is assessed based on the following
standards for participating practitioners:
An individual with life-threatening emergency needs is seen immediately
An individual with non-life-threatening emergency needs is seen within six (6) hours
An individual with urgent needs is seen within 48 hours
Routine office visits are available within 10 business days
Routine follow-up office visits for non-prescribers are available within 30 business days of initial
visit
Routine follow-up office visits for prescribers are available within 90 business days of initial visit
The following methods may be used to monitor participating provider behavioral health service availability
and member access to care:
Analysis of member complaints and grievances related to availability and access to care
66
Member satisfaction surveys specific to their experience in accessing care and routine
appointment availability
Open shopper staff surveys for appointment availability—an approach to measuring timeliness of
appointment access in which a surveyor contacts participating provider’s offices to inquire about
appointment availability and identifies from the outset of the call that he or she is calling on behalf
of Beacon
Referral line calls are monitored for timeliness of referral appointments given to members
Analysis and trending of information on appointment availability obtained during site visits
Analysis of call statistics (e.g., average speed of answer, abandonment rate over five seconds)
Annual Geo-Access and network density analysis (see Network policies and procedures)
In addition to these monitoring activities, participating providers are required by contract to report to
network management when they are at capacity. This assists customer service in selecting appropriate,
available participating practitioners for member referral.
13.06 Healthcare Effectiveness Data and Information Set (HEDIS
®
6
)
There are a number of ways to monitor the treatment of individuals with mental health and/or substance
use conditions receive. Many of you who provide treatment to these individuals measure your
performance based on quality indicators such as those to meet CMS reporting program requirements;
specific state or insurance commission requirements; managed care contracts; and/or internal metrics. In
most cases there are specific benchmarks that demonstrate the quality that you strive to meet or exceed.
Beacon utilizes a number of tools to monitor population-based performance in quality across regions,
states, lines of business and diagnostic categories. One such tool is the Healthcare Effectiveness Data
and Information Set (HEDIS) behavioral health best practice measures as published by the National
Committee for Quality Assurance (NCQA) as one of our tools. Like the quality measures utilized by CMS,
Joint Commission, and other external stakeholders, these measures have specific, standardized rules for
calculation and reporting. The HEDIS measures allow consumers, purchasers of health care and other
stakeholders to compare performance across different health plans.
While the HEDIS measures are population-based measures of our partner health plan performance and
major contributors to health plan accreditation status, our partner health plans rely on us to ensure
behavioral health measure performance reflects best practice. Our providers are the key to guiding their
patient to keep an appointment after leaving an inpatient psychiatric facility; taking their antidepressant
medication or antipsychotic medication as ordered; ensuring a child has follow up visits after being
prescribed an ADHD medication; and ensuring an individual with schizophrenia or bipolar disorder has
annual screening for diabetes and coronary heart disease.
There are six domains of care and service within the HEDIS library of measures:
1. Effectiveness of Care
2. Access and Availability
3. Utilization and Relative Resource Use
4. Measures Collected Using Electronic Clinical Data Systems (ECDS)
6
HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA).
67
5. Experience of Care
6. Health Plan Descriptive Information
A brief description of these measures:
1. Effectiveness of Care: Measures that are known to improve how effective care is delivered. One
very important measure in this domain is Follow-up after Mental Health Hospitalization (Aftercare). In
effect, this means how long someone waits to get mental health care after they are discharged from
an inpatient mental health hospital. To prevent readmission and help people get back into the
community successfully, best practice is from seven to thirty days after discharge.
2. Access/Availability: Measures how quickly and frequently members receive care and service within
a specific time. For example, the Initiation and Engagement of Drug and Alcohol Abuse Treatment
measure relies on frequency and timeliness of treatment to measure treatment initiation and
treatment engagement. Studies show that an individual who engages in the treatment process have
better outcome and success in recovery and sobriety.
3. Utilization and Relative Resource Use: This domain includes evidence related to the management
of health plan resources and identifies the percentage of members using a service. For example,
Beacon measures Mental Health Utilization and Plan All Cause Readmissions.
4. Measures Collected Using Electronic Clinical Data Systems (ECDS): This is the newest domain,
and it requires calculation of outcomes by accessing data through the electronic submission of a
member’s electronic health record (EHR). An example of an ECDS measure is the Utilization of the
PHQ-9. This demonstrates whether a PHQ-9 was administered to a patient with depression four
months after initiation of treatment to measure response to treatment.
5. Experience of Care: This domain is specific to health plans.
6. Health Plan Descriptive Information: We supply Board Certification of physicians and psychologists
to the plan; all other information is specific to the health plan.
Below is a brief description of the HEDIS measures that apply to the behavioral health field requirements
associated with each:
1. Follow-up after Hospitalization for Mental Illness
Best practice for a member aged six or older to transition from acute mental health treatment to the
community is an appointment with a licensed mental health practitioner (outpatient or intermediate
treatment) within seven and/or 30 calendar days of discharge.
For this measure, NCQA requires organizations to substantiate by documentation from the member’s
health record all nonstandard supplemental data that is collected to capture missing service data not
received through claims, encounter data, laboratory result files, and pharmacy data feeds. Beacon
requires proof-of-service documentation from the member’s health record that indicates the service
was received. All proof-of-service documents must include all the data elements required by the
measure. Data elements included as part of the patient’s legal medical record are:
Member identifying information (name and DOB or member ID)
Date of service
DSM diagnosis code
Procedure code/Type of service rendered
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Provider site/facility
Name and licensure of mental health practitioner rendering the service
Signature of rendering practitioner, attesting to the accuracy of the information
The critical pieces of this measure for providers/participating providers are:
Inpatient facilities need to:
o Use accurate diagnoses when submitting claims for inpatient treatment. If the
diagnosis on admission is a mental health diagnosis but subsequent evaluation
during the stay confirms that the primary diagnosis is substance use, please use the
substance use diagnosis on the claim submitted at discharge.
o Ensure that discharge planners educate patients about the importance of aftercare
for successful transition back to their communities.
o Ensure that follow-up visits are within seven calendar days of discharge. Note: It is
important to notify the provider/participating providers that the appointment is post
hospital discharge and that an appointment is needed in seven calendar days.
o Ensure that the appointment was made with input from the patient. If the member has
a pre-existing provider and is agreeable to going back to that provider schedule the
appointment with that provider. If not, the location of the outpatient provider or PHP,
IOP or other alternative level of care, must be approved by the member and be
realistic and feasible for the member to keep that appointment.
Outpatient providers/participating providers need to make every attempt to schedule
appointments within seven calendar days for members being discharged from inpatient care.
Providers/participating providers are encouraged to contact those members who are “no
show” and reschedule another appointment.
2. Initiation and Engagement of Alcohol and other Drug Use Treatment
This measure aims to define best practice for initial and early treatment for substance use disorders
by calculating two rates using the same population of members who receive a new diagnosis of
Alcohol and Other Drug (AOD) use from any provider (ED, Dentist, PCP, etc.):
Initiation of AOD Use Treatment: The percentage of adults diagnosed with AOD Use who
initiate treatment through either an inpatient AOD admission or an outpatient service for AOD
from a substance use provider AND an additional AOD service within 14 calendar days.
Engagement of AOD Treatment: An intermediate step between initially accessing care and
completing a full course of treatment. This measure is designed to assess the degree to
which the members engage in treatment with two additional AOD services within 30 calendar
days after initiation phase ends. The services that count as additional AOD services include
IOP, Partial Hospital, or outpatient treatment billed with CPT-4 or revenue codes associated
with substance use treatment.
3. Antidepressant Medication Management (AMM)
The components of this measure describes best practice in the pharmacological treatment of newly
diagnosed depression treated with an antidepressant by any provider by measuring the length of time
the member remains on medication. There are two treatment phases:
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Acute Phase: The initial period of time the member must stay on medication for the majority
of symptoms to elicit a response is 12 weeks
Continuation Phase: The period of time the member must remain on medication in order to
maintain the response is for at least six months.
4. Follow-Up Care for Children Prescribed Attention-Deficit/Hyperactivity Disorder (ADHD)
Medication
The components of this measure describes best practice in the pharmacological management of
children 6-12 years newly diagnosed with ADHD and prescribed an ADHD medication by measuring
the length of time between initial prescription and a follow up psychopharmacology visit and the
continuation and maintenance phases of treatment.
Initiation Phase: For children, 6-12 years of age, newly prescribed ADHD medication best
practice requires a follow up visit with a prescriber within 30 days of receiving the medication.
For ongoing treatment with an ADHD medication, best practice requires:
Continuation and Maintenance (C&M) Phase: At least two additional follow-up visits with a
prescriber in the preceding nine months; and, the child remains on the medication for at least
seven months.
5. Diabetes Screening for People with Bipolar Disorder or Schizophrenia Who Are Using
Antipsychotic Medications (SSD)
For members with Schizophrenia or Bipolar diagnosis who were being treated with an antipsychotic
medication, this measure monitors for potential Type 2 Diabetes with an HbA1C test.
6. Diabetes Monitoring for People with Diabetes and Schizophrenia Who are Using Antipsychotic
Medications (SMD)
For members who have Type 2 Diabetes, a Schizophrenic or Bipolar diagnosis and are being treated
with an antipsychotic this measure’s best practice is an annual or more frequent LDL-C test and an
HbA1c test (SMD).
7. Cardiovascular Monitoring for People with Cardiovascular Disease and Schizophrenia (SMC)
For members with Schizophrenia or Bipolar diagnosis who are being treated with an antipsychotic
medication this measure monitors for potential cardiac disease with a LDL-C test.
8. Adherence to Antipsychotic Medications for Individuals with Schizophrenia (SAA)*
This measure is described as the percentage of members 19-64 years of age during the
measurement year with schizophrenia who were dispensed and remained on an antipsychotic
medication for at least 80 percent of their treatment period.
9. Metabolic Monitoring for Children and Adolescents on Antipsychotics (APM)
For child and adolescent members (1-17) prescribed antipsychotic medication on an ongoing basis,
best practice requires testing at least annually during the measurement year to measure glucose
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levels (Blood Glucose or HbA1C) and cholesterol levels to monitor for development of metabolic
syndrome.
10. Use of Multiple Concurrent Antipsychotics in Children and Adolescents (APC)
This measure identifies children and adolescents who are on two or more concurrent antipsychotic
medications.
The best practice here is that multiple concurrent use of antipsychotic medications is not best practice
nor approved by the FDA. While there are specific situations where a child or adolescent requires
concurrent medications, the risk/benefit of the treatment regime must be carefully considered and
monitoring in place to prevent adverse outcome.
11. Use of First-Line Psychosocial Care for Children and Adolescents on Antipsychotics (APP)
For children and adolescents with a new prescription for an antipsychotic, best practice requires that
the child receive psychosocial care as part of first line treatment.
First line treatment is associated with improved outcomes and adherence.
12. Utilization of the PHQ-9 to Monitor Depression for Adolescents and Adults (DMS)
For members diagnosed with depression treated in outpatient settings the PHQ-9 or PHQ-A
(adolescent tool) must be administered by the outpatient provider at least once during a four-month
treatment period.
13. Depression Remission or Response for Adolescents and Adults (DRR)
The percentage of members 12 years of age and older with a diagnosis of depression and an
elevated PHQ-9 score, who had evidence of response or remission within five to seven months of the
elevated score. Four rates are reported:
ECDS Coverage. The percentage of members 12 and older with a diagnosis of major
depression or dysthymia, for whom a health plan can receive any electronic clinical quality
data.
Follow-Up PHQ-9. The percentage of members who have a follow-up PHQ-9 score
documented within the five to seven months after the initial elevated PHQ-9 score.
Depression Remission. The percentage of members who achieved remission within five to
seven months after the initial elevated PHQ-9 score.
Depression Response. The percentage of members who showed response within five to
seven months after the initial elevated PHQ-9 score.
Note: These measures are collected utilizing Electronic Clinical Data Sets (ECDS) as found in the
provider’s Electronic Medical Record. While NCQA/HEDIS is looking to expand the options for
collecting this data, Beacon has yet to begin discussing this requirement with providers.
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14. Follow-up After Emergency Department Visit for Mental Illness (FUM)
The percentage of emergency department (ED) visits for members six years of age and older with a
principal diagnosis of mental illness, who had a follow-up visit for mental illness. Two rates are
reported:
Follow-up visit to occur within seven days of ED discharge.
If the seven-day visit goal is missed, the next goal is a visit within 30 days of ED discharge.
15. Follow-up After Emergency Department Visit for Alcohol or Other Drug Dependence (FUA)
The percentage of emergency department (ED) visits for members 13 years of age and older with a
principal diagnosis of alcohol or other drug (AOD) dependence, who had a follow up visit for AOD.
Two rates are reported:
Follow-up visit to occur within seven days of ED discharge.
If the seven-day visit goal is missed, the next goal is a visit within 30 days of ED discharge.
Here is the complete list of HEDIS Behavioral Health measures:
Effectiveness of Care:
AMM: Antidepressant Medication Management
ADD: Follow-Up Care for Children Prescribed ADHD Medication
FUH: Follow-Up After Hospitalization for Mental Illness
SSD: Diabetes Screening for People with Schizophrenia or Bipolar Disorder Who Are Using
Antipsychotic Medications
SMD: Diabetes Monitoring for People with Diabetes and Schizophrenia
SMC: Cardiovascular Monitoring for People with Cardiovascular Disease and Schizophrenia
SAA: Adherence to Antipsychotic Medications for Individuals with Schizophrenia
APC: Use of Multiple Concurrent Antipsychotics in Children and Adolescents
APM: Metabolic Monitoring for Children and Adolescents on Antipsychotics
FUM: Follow-up After Emergency Department Visit for Mental Illness
FUA: Follow-up After Emergency Department Visit for Alcohol and Other Drug Dependence
Other Domains:
Access and Availability
IET: Initiation and Engagement of Alcohol and Other Drug Dependence Treatment
APP: Use of First-Line Psychosocial Care for Children and Adolescents on Antipsychotics
Utilization/Relative Resource Use - Utilization
PCR: Plan All-Cause Readmissions
IAD: Identification of Alcohol and Other Drug Services
MPT: Mental Health Utilization
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Health Plan Descriptive Information
BCR: Board Certification
Electronic Clinical Data Systems
DMS: Utilization of the PHQ-9 to Monitor Depression Symptoms for Adolescents and Adults
DRR: Depression Remission or Response for Adolescents and Adults
13.07 Continuity and Coordination of Care
Beacon monitors continuity and coordination of care throughout its continuum of behavioral health
services. Monitoring may include reviews and audits of treatment records, coordination of discharge
planning between inpatient and outpatient providers/participating providers, and monitoring
provider/participating provider performance on pre-determined coordination of care indicators. Processes
are established seeking to avoid disruption of care for the member when there is a change in their
treating provider/participating provider. Such changes may include, but are not limited to:
A member requires a change in level of care, necessitating a new participating provider
There are multiple providers/participating providers involved in treatment simultaneously
(psychiatrist for medication management, therapist for on-going treatment)
A change in health plans or benefit plans
Termination of a participating provider
A member is being treated for several (co-morbid) conditions simultaneously with multiple
providers/participating providers (both behavioral health specialists, primary care, medical
specialists, or providers specializing in developmental disabilities)
13.08 Screening Programs
Beacon supports the early detection and treatment of depressive and comorbid disorders to promote
optimal health for members 13 years and older.
A few helpful reminders:
Beacon offers many screening tools and programs available at no cost:
PCP/ Provider Toolkit
Depression Screening Program (PDF)
Comorbid Mental Health and Substance Use Disorder Screening Program (PDF)
Use screening tools at the first visit and repeat at regular intervals as clinically indicated to identify
potential symptoms that may need further evaluation.
Depression
Patient Health Questionnaire 9 (PHQ-9) is a brief, multi-purpose tool for assessing
depression, and is available in English, Spanish, and a variety of other languages in
Beacon’s PCP/ Provider Toolkit.
When assessing for depression, remember to rule out bipolar disorders; you may choose
to use the Mood Disorder Questionnaire (MDQ).
Suicide
Beacon endorses the National Action Alliance for Suicide Prevention’s Recommended
Standard Care for People with Suicide Risk, which screens individuals for suicide and
includes a list of screening tools in the Appendix.
Comorbid issues
Remember to screen for possible mental health disorders when a diagnosis of a substance
use disorder is present and conversely to screen for a potential substance use disorder
when a mental health disorder is present.
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The CRAFFT Screening Interview (PDF) assesses for substance use risk specific to adolescents.
Learn more about Beacon’s Depression Screening Program and Comorbid Screening Program at the
attached links.
13.09 Treatment Record Standards and Guidelines
Member treatment records should be maintained in compliance with all applicable medical standards,
privacy laws, state and federal rules and regulations, as well as Beacon’s policies and procedures and in
a manner that is current, comprehensive, detailed, organized and legible to promote effective patient care
and quality review. Providers are encouraged to use only secure electronic medical record technology
when available. Beacon’s policies and procedures incorporate standards of accrediting organizations to
which Beacon is or may be subject (e.g., NCQA and URAC), as well as the requirements of applicable
state and federal laws, rules, and regulations.
References to ‘treatment records’ mean the method of documentation, whether written or electronic, of
care and treatment of the member, including, without limitation, medical records, charts, medication
records, physician/practitioner notes, test and procedure reports and results, the treatment plan, and any
other documentation of care and/or treatment of the member.
Progress notes should include what psychotherapy techniques were used, and how they benefited the
member in reaching his/her treatment goals. Progress notes do not have to include intimate details of the
member’s problems but should contain sufficient documentation of the services, care, and treatment to
support medical necessity of same. Intimate details documenting or analyzing the content of
conversations during a private counseling session or a group, joint, or family counseling session should
be maintained within the psychotherapy notes and kept separate from the member’s treatment record
made available for review and audit.
Member treatment record reviews and audits are based on the record keeping standards set out below:
Each page (electronic or paper) contains the member’s name or identification number.
Each record includes the member’s address, employer or school, home and work telephone
numbers including emergency contacts, marital or legal status, appropriate consent forms and
guardianship information, if relevant.
All entries in the treatment record are dated and include the responsible clinician’s name,
professional degree, and relevant identification number (if applicable), and modality of treatment
(office-based or telehealth (if telehealth video, phone or other modality). The length of the
visit/session is recorded, including visit/session start and stop times.
Reviews may include comparing specific entries to billing claims as part of the record review.
The record, when paper based is legible to someone other than the writer.
Medication allergies, adverse reactions and relevant medical conditions are clearly documented
and dated. If the member has no known allergies, history of adverse reactions or relevant medical
conditions, this is prominently noted.
Presenting problems, along with relevant psychological and social conditions affecting the
member’s medical and psychiatric status and the results of a mental status exam, are
documented.
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Special status situations, when present, such as imminent risk of harm, suicidal ideation or
elopement potential, are prominently noted, documented, and revised in compliance with written
protocols.
Each record indicates what medications have been prescribed, the dosages of each and the
dates of initial prescription or refills.
A medical and psychiatric history is documented, including previous treatment dates, practitioner
identification, therapeutic interventions and responses, sources of clinical data, and relevant
family information.
For children and adolescents, past medical and psychiatric history includes prenatal and perinatal
events (when available), along with a developmental history (physical, psychological, social,
intellectual and academic).
For members 12 and older, documentation includes past and present use of cigarettes and
alcohol, as well as illicit, prescribed, and over-the-counter drugs.
A DSM (or the most current version of the DSM) diagnosis is documented, consistent with the
presenting problems, history, mental status examination, and/or other assessment data.
Treatment plans are consistent with diagnoses, have both objective, measurable goals and
estimated timeframes for goal attainment or problem resolution, and include a preliminary
discharge plan, if applicable.
Treatment plans are updated as needed to reflect changes/progress of the member.
Continuity and coordination of care activities between the primary clinician, consultants, ancillary
providers, and health care institutions are documented as appropriate.
Informed consent for medication and the member’s understanding of the treatment plan are
documented.
Additional consents are included when applicable (e.g., alcohol and drug information releases).
Progress notes describe the member’s strengths and limitations in achieving treatment plan goals
and objectives and reflect treatment interventions that are consistent with those goals and
objectives.
Documented interventions include continuity and coordination of care activities, as appropriate.
Dates of follow-up appointments or, as applicable, discharge plans are noted.
In addition to other requests for member treatment records included in this handbook and/or the provider
agreement, member treatment records are subject to targeted and/or unplanned reviews by the Beacon
Quality Management Department or its designee, as well as audits required by state, local, and federal
regulatory agencies and accreditation entities to which Beacon is or may be subject to.
13.10 Treatment Record Reviews
Participating providers are required to cooperate with treatment record reviews and audits conducted by
Beacon and associated requests for copies of member records. For the purpose of conducting
retrospective case reviews, treatment records for Beacon members should be maintained for the time
period(s) required by applicable state and/or federal laws and/or regulations, and as detailed in the
provider agreement.
Beacon may conduct treatment record reviews and/or audits:
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On an unplanned basis as part of continuous quality improvement and/or monitoring activities
As part of routine quality and/or billing audits
As may be required by clients of beacon
In the course of performance under a given client contract
As may be required by a given government or regulatory agency
As part of periodic reviews conducted pursuant to accreditation requirements to which Beacon is
or may be subject
In response to an identified or alleged specific quality of care, professional competency or
professional conduct issue or concern
As may be required by state and/or federal laws, rules, and/or regulations
In the course of claims reviews and/or audits
As may be necessary to verify compliance with the provider agreement
Beacon treatment record standards and guidelines for member treatment record reviews
conducted as part of quality management activities are set out in the quality management section
of this handbook.
Treatment record reviews and/or audits may be conducted through on-site reviews in the participating
provider’s office or facility location, and/or through review of electronic or hard copy of documents and
records supplied by the participating provider. Unless otherwise specifically provided for in the provider
agreement and/or other sections of this handbook with respect to a particular type of record review or
audit, participating providers must supply copies of requested records to Beacon within five business
days of the request.
Beacon will use and maintain treatment records supplied by participating providers for review and/or audit
in a confidential manner and in accordance with applicable laws and regulations regarding the privacy or
confidentiality of protected health information and/or patient identifying information. Never send original
records as they will not be returned at the completion of the review or audit. Only send those sections of
the record that are requested. Unless otherwise specifically provided in the provider agreement, access
to and any copies of member treatment records requested by Beacon or designees of Beacon shall be at
no cost. Records are reviewed by licensed clinicians. Treatment records reviews and/or audits conducted
as part of Quality Management activities include application of an objective instrument(s). The
instrument(s) are reviewed at least annually; Beacon reserves the right to alter/update, discontinue and/or
replace such instruments in its discretion and without notice.
Following completion of treatment record reviews and/or audits, Beacon will give the participating provider
a written report that details the findings. If necessary, the findings report will include a corrective action
plan with specific recommendations that will enable the participating provider to more fully comply with
Beacon standards for treatment records.
Participating providers will grant access for members to the member’s treatment records upon written
request and with appropriate identification. Participating providers should review member treatment
records prior to granting access to members to ensure that confidential information about other family
members and/or significant others that may be referenced and/or included therein is redacted.
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13.11 Member Safety Program
Beacon has a defined procedure for the identification, reporting, investigation, resolution and monitoring
of Potential Quality of Care (PQOC) concerns. PQOC concerns are those that decrease the likelihood of
desired health outcomes and that are inconsistent with current professional knowledge. These types of
issues may be identified from a variety of sources, including without limitation member and
provider/participating provider complaints, internal reviews, clients, government agencies and others.
These concerns are resolved and monitored at both the region and network-wide level. Regional teams
have a designated committee, in which the local medical director participates, that oversee the
investigation and resolution of these issues through to completion.
Beacon’s member safety program includes the following components: prospective identification and
reporting and investigation of potential Serious Reportable Events (internal and external events), trend
analysis of member and provider and client complaints, annual evaluation and updating of existing
member safety policies, prevention activities and the promotion of evidenced-based practice by our
network credentialed providers and Beacon employed clinicians.
Prior to 6/1/2020, Beacon’s Member Safety Program utilized a model of Adverse Incidents and Quality of
Care Concerns. Effective 6/1/2020, Beacon’s Member Safety Program utilizes a model of Potential
Quality of Care (PQOC) Concerns including Serious Reportable Events (SREs) and Trending Events
(TE). Beacon adopted the National Quality Forum’s (NQF) Serious Reportable Event classification system
as a base for its Member Safety Program. This allows the use of a standard taxonomy across a wide
variety of settings and supports standard definitions across our diverse organization. For some contracts
the term adverse incident, sentinel event or major incident may be used interchangeably or may have a
specific definition based on state requirements.
Serious Reportable Events (SRE) include, but are not limited to:
1. Surgical or Invasive Procedures (i.e., wrong site, wrong patient, wrong procedure, foreign
object, and death of ASA class 1 patient)
2. Product or Device Events (i.e., contamination, device malfunction, and embolism)
3. Patient Protection Events (i.e. discharge of someone unable to make decisions, elopement,
completed suicide, attempted suicide, and self-injurious behaviors)
4. Care Management Events (i.e., medication error, fall)
5. Environmental Events (i.e., electric shock, gas, burn, restraint, seclusion, restrictive
interventions)
6. Potential Criminal Events (i.e., impersonation, abduction, physical assault, and sexual
behavior)
7. Beacon Specific (such as disaster management, accidents, staff misconduct, standards of
care, and natural death)
Trending Events (TE) include, but are not limited to the following categories/sub-categories:
Provider inappropriate/unprofessional behavior
Inappropriate boundaries/relationship with member
Practitioner not qualified to perform services
Aggressive behavior
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Displays signs of cognitive, mental health, or substance use concerns impacting the
care being provided
Clinical practice-related issues
Abandoned member or inadequate discharge planning
Timeliness, accuracy, or adequacy of diagnosis, assessment, or referral
Delay in treatment
Effectiveness of treatment
Failure to coordinate care or follow clinical practice guidelines
Failure to involve family in treatment when appropriate
Medication error or reaction
Treatment setting not safe
Access to care-related issues
Failure to provide appropriate appointment access
Lack of timely response to telephone calls
Prolonged in-office wait time or failure to keep appointment
Provider non-compliant with American Disabilities Act (ADA) requirements
Services not available or session too short
Attitude and service-related issues
Failure to allow site visit
Failure to maintain confidentiality
Failure to release medical records
Fraud and abuse
Lack of caring/concern or poor communication skills
Poor or lack of documentation
Provider/staff rude or inappropriate attitude
Other monitored events
Adverse reaction to treatment
Failure to have or follow communicable disease protocols
Human rights violations
Ingestion of an unauthorized substance in a treatment setting
Non-serious injuries (including falls)
Property damage and/or fire setting
Sexual behavior
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Participating providers are required to report to Beacon within 24 hours all Potential Quality of Care
(PQOC) concerns involving members. Beacon investigates Potential Quality of Care Concerns (PQOC)
and uses the data generated to identify opportunities for improvement in the clinical care and service
members receive. Beacon tracks and trends PQOC concerns and when necessary, investigates patterns
or prevalence of incidents and uses the data generated to identify opportunities for quality improvement.
Based on the circumstances of each incident, or any identified trends, Beacon may undertake an
investigation designed to provide for member safety. As a result, participating providers may be asked to
furnish records and/or engage in corrective action to address quality of care concerns and any identified
or suspected deviations from a reasonable standard of care. Participating providers may also be subject
to disciplinary action through the NCC based on the findings of an investigation or any failure to
cooperate with a request for information pursuant to an adverse incident investigation.
13.12 Professional Review/Fair Hearing Process
Individual providers/participating providers, where required by applicable law, may request a second level
of appeal/a fair hearing when the PAC denies credentialing or re-credentialing, issues a sanction, or
recommends termination of participation status of the provider from the Beacon provider network, where
such denial, sanction, or recommendation is based on quality of care issues and/or issues related to
professional competence or professional conduct. Information about the fair hearing process is located in
the appeals section of this handbook.
13.13 Quality Improvement Activities/Projects
One of the primary goals of Beacon’s National Quality Management Program (QMP) is to continuously
improve care and services. Through data collection, measurement and analysis, aspects of care and
service that demonstrate opportunities for improvement are identified and prioritized for quality
improvement activities. Data collected for quality improvement projects and activities are frequently
related to key industry measures of quality that tend to focus on high-volume diagnoses or services and
high-risk or special populations. Data collected are valid, reliable and comparable over time. Beacon
takes the following steps to ensure a systematic approach to the development and implementation of
quality improvement activities:
Monitoring of clinical quality indicators
Review and analysis of the data from indicators
Identification of opportunities for improvement
Prioritization of opportunities to improve processes or outcomes of behavioral health care delivery
based on risk assessment, ability to impact performance, and resource availability
Identification of the affected population within the total membership
Identification of the measures to be used to assess performance
Establishment of performance goals or desired level of improvement over current performance
Collection of valid data for each measure and calculation of the baseline level of performance
Thoughtful identification of interventions that are powerful enough to impact performance
Analysis of results to determine where performance is acceptable and, if not, the identification of
current barriers to improving performance
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13.14 Experience Surveys (formerly known as Satisfaction Surveys)
When delegated, Beacon, either directly or through authorized designees, conducts some form of
experience survey to identify areas for improvement as a key component of the QMP. Experience survey
participation may include members, participating providers, and/or clients.
Member experience surveys measure opinions about clinical care, participating providers, and Beacon
administrative services and processes. Members are asked to complete satisfaction surveys at various
points in the continuum of care and/or as part of ongoing quality improvement activities. The results of
these member surveys are summarized on an annual basis. Where appropriate, corrective actions are
implemented in the Beacon functional department or as applicable in the Region.
Annual participating provider satisfaction surveys measure opinions regarding clinical and administrative
practices. The results of participating provider surveys are aggregated and used to identify potential
improvement opportunities within Beacon and possible education or training needs for participating
providers. Where appropriate, corrective actions are implemented in the Beacon functional department or
as applicable in the Region.
13.15 Member Complaints and Grievances
One method of identifying opportunities for improvement in processes at Beacon is to collect and analyze
the content of member complaints. The Beacon complaints and grievance process has been developed
to provide a structure for timely responses and to track and trend complaint and grievance data by
type/category. Complaint and grievance data is compiled and reported to the local clinical quality
committees at least semi-annually.
