Specialty Networks and Forms (Appendix F)
Specialty Networks
Evernorth Behavioral Health has identified clinical specialties that require specific attestation of competency by practitioners or verification of licensure by Evernorth Behavioral Health, in order to list the specialty as an area of clinical practice. Evernorth Behavioral Health staff will utilize a variety of means to ensure that the specialties listed in a practitioner's record are accurate, to promote quality customer care. The verification process will be completed during initial credentialing, when the practitioner requests to add a specialty to their profile, and during the recredentialing process. There are currently three different groups of specialties: self-reported specialties, attested specialties and verified specialties. Definition of Self-Reported Specialties: Specialties that can be listed as an area of practice based upon a practitioner's selection. Self-reported specialties include general areas of behavioral health treatment for which practitioners have received training as a licensed behavioral health practitioner.
Self-reported specialties include: Depression, Anxiety, Couples Counseling, Anger Management, Grief/Loss, LGBTQ+, Domestic Violence and Faith-based Counseling. Definition of Attested Specialties: Specialties that can be listed as an area of practice based on education and experience, but do not require additional documentation.
Attested Specialties include: Sexual Disorders/Offenders, Autism, EAP (CIR, CEAP, Assessment/Referral, Employment Education, Management Referrals, Supervisor Training,) Developmental Disorders, DBT, Dual Diagnosis, Eating Disorders, EMDR, Neuropsychological testing, and Pain Management.
Definition of Verified Specialties: Practitioner has documentation, such as specific licensure or certification, to substantiate ability to provide specialty services.
Verified Specialties Include: Addictionology, Alcohol/Substance Use, Behavioral Pediatricians, Buprenorphine, Medication Management, SAP, SAE.
If a practitioner does not meet the criteria for any of the attested and/or verified specialties, these specialties will not be added to the practitioner's profile. If at any point Evernorth Behavioral Health has been made aware that a practitioner no longer meets criteria for an attested or verified specialty, the specialty will be removed from the practitioner's data profile. This will not affect the practitioner’s network status or payment for services.
However, participants needing these specialty services will only be referred by Evernorth Behavioral Health to those practitioners who have that specialty listed within their profile.
If you wish to add a verified or attested specialty to your profile, please utilize the following Verified Specialties and/or Attested Specialties form(s). To add specialties that are not included on the following forms (i.e. Self-Reported Specialties) please contact Provider Services at 800.926.2273.
Crisis Stabilization and Intermediate Care
Evernorth Behavioral Health is committed to providing excellent service and quality of care to participants. Evernorth Behavioral Health Clinical Operations and Provider Relations staff have worked together to better understand crisis stabilization services. As a result, Evernorth Behavioral Health has defined crisis stabilization services to provide different access levels based on the participant's needs.
Crisis Stabilization Unit
The use of Crisis Stabilization Unit may apply in those cases where a Crisis Stabilization Unit exists outside of an accredited hospital, but where 24-hour supervised and monitored services are available. The facility setting for a crisis stabilization bed, is within a unit that provides around-the-clock nursing and/or mental health staff supervision and continuous observation and control of behaviors to insure the safety of the individual and/or others.
- This level of care is for short-term crisis stabilization for those experiencing a mental health emergency.
- The purpose is to prevent further decompensation that would result in an inpatient admission.
- The typical length of stay is 1-7 days
This service provides:
- Evaluation and intervention for individuals with acute symptoms of a behavioral health or substance use disorder when the clinical presentation does not immediately indicate the need for a higher level of care.
- 24-hour supervised and monitored services
- Psychiatric consultation
- Evaluation of family and social support systems that identify both opportunities and challenges, and a plan to address the latter
- Linkage and referrals to long-term services/community services
- An individualized treatment plan
- May provide medication management
- May provide individual and group and family counseling
- A complete medical evaluation and basic medical procedures as indicated.
Note: When medical services are not available on site, the program must be able to ensure that the individual will be linked to appropriate treatment and providers within a reasonable timeframe.
The goals of the intervention at this level of care:
- Reduction of acute symptoms due to a mental health disorder or substance use disorder
- Reduction of potential for harm to self or others
- Active interventions within 6 hours of admission by a mental health clinician
- Identification and mobilization of available resources including support networks
- Intervention focused on factors relevant to the crisis.
Appropriate Interventions include assessment of support networks, identification and assessment of available services, mobilization of those services, and an estimate of the individual's ability to access services and participate in the treatment plan.
Note: This level of care is not appropriate for an individual who, by clinical presentation or history, requires the intensive structure of Acute Inpatient Treatment for safely and stabilization.
Intermediate Care
Intermediate Care is a level of intervention that provides precautionary and preventive care to a participant who presents with a level of acuity that if not addressed within 48-hours, could escalate to a higher level of care. The goal of our Intermediate Care network is to successfully link complex cases with practitioners who have the clinical expertise to manage specific diagnoses/problems for ongoing treatment. It is expected the intervention be conducted by a licensed mental health provider, the key elements being to assess, stabilize and proactively identify the most appropriate level of care for the participant at that time. The intervention should include the following components:
- A comprehensive psychiatric and medical history
- A description of the nature of the participant's impairments and the nature of any safety or risk issues (S/I, H/I)
- Comprehensive evaluation of substance use or chemical dependency issues
- A psychosocial evaluation including a systems analysis of the participant's family and support network. Identify any barriers for successful treatment plan
- Documentation of any current treatment practitioners, description of the services provided and medications, if any (including names, dosages, and frequencies on meds prescribed)
Following is a list of key objectives for Intermediate Care services:
- Practitioners will be able to intensify treatment plans as needed for their participants in order to prevent unnecessary hospitalization as clinical indicated
- Practitioners will develop short-term, evidenced-based treatment plans incorporating a systems approach
- Practitioners will include in their treatment planning, effective collaboration between Evernorth Behavioral Health, psychiatrists, PCP's and other community resources prior to requesting any higher level of care
Notes
If the acuity of the participant's condition does not allow for preauthorization of coverage, contact Evernorth Behavioral Health as soon as possible. Please be prepared to provide the following information to the Evernorth Behavioral Health clinical staff:
- Participant's name, age, and participant identification number.
- History, diagnosis, indications, and nature of the immediate crisis.
- Alternative treatment provided or considered.
- Treatment goals, estimated length of stay, and discharge plans.
Meet and Greet Appointments
A Meet-&-Greet appointment is a pre-discharge visit conducted by a participating non-MD practitioner for the purpose of coordinating and scheduling the ambulatory follow-up appointment, 2-7 days after discharge. The practitioner will enter the facility as a visitor; therefore, the practitioner does not need to be credentialed with the facility. Please note that the Meet-&-Greet service is usually performed during visiting hours, but scheduling may vary by facility.
A Meet-&-Greet appointment is an Evernorth Behavioral Health-initiated service for which prior authorization must be obtained from an Evernorth Behavioral Health care manager or care coordinator. Claims should be submitted with Current Procedural Terminology (CPT®) code 99499 (unlisted evaluation/management services). The claim will be processed for benefit as long as there is a comment in the inpatient authorization and the practitioner includes a written description of the service provided, i.e. "pre-discharge consultation" or "Meet-&-Greet". Without a written description by the practitioner, the claim payment will be denied due to lack of information. A co-pay for this service depends upon the participant's benefit plan.
Behavioral Telehealth
Therapy and medication management telehealth sessions are available to customers nationwide and related claims will be administered in accordance with the customer’s benefit plan. Offering services via telehealth to customers gives you the potential to broaden the scope of your practice, earn additional income during “off” hours, reach patients in a larger geographical area, expand access to mental health care, and reduce your time on the road.
You must be appropriately licensed in the state in which the customer is being treated. Use of a secure video-based technology* is preferred as it can provide you with information and a patient experience that is similar to an in-person examination. You must also be aware of relevant in-person and telehealth practice guidelines. You are expected to follow federal, state and local regulatory and licensure requirements related to your scope of practice, any limitations on the use of specific technologies and prescribing practices, and need to abide by state board and specialty training requirements.
Contracted behavioral providers who meet the telehealth specialty requirements may deliver services via telehealth with no additional credentialing. To provide telehealth sessions to customers, please attest to meeting the designated specialty requirements on the Attested Specialty Form. Upon receipt and approval by Evernorth of the completed form, “telehealth” will be added as a specialty to your profile.
*Telephonic sessions are not considered to be a substitute for face-to-face or video therapy visits and require that specific criteria be met for approval.
Forms