Behavioral Health

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Additional Information
Effective January 1, 2008, Empire has assumed responsibility for managing behavioral health and substance abuse benefit services for more than two million members, through an internal department. Empire’s behavioral health provider network is open to Psychiatrists, Psychiatric Nurse Practitioners, Psychologists and Licensed Clinical Social Workers who are successfully credentialed through Empire. Member benefits will vary based on Plan and Product, it is recommended that benefits and eligibility are verified prior to treatment commencing, to ensure participation and accurate utilization management rules are applied throughout treatment.  
Behavioral Health Follow Up Program (FUAH)
Outpatient Behavioral Health Pass-Through Visits
 
The Behavioral Health Medical Necessity Criteria document has been divided into several Clinical UM Guidelines and can be found at the link below under the Behavioral Health category:

Behavioral Health Clinical UM Guidelines
– CG-BEH-03 – Psychiatric Disorder Treatment
– CG-BEH-04 – Substance Abuse Treatment
– CG-BEH-05 – Eating Disorder Treatment
– CG-BEH-06 – Psychiatric Outpatient Treatment
– CG-BEH-07 – Psychological Testing

Other Medical Policies and Clinical UM Guidelines can be found at this link: Medical Policies and Clinical UM Guidelines
 

Forms

Outpatient Treatment Report (OTR)

PDF Format

Applied Behavior Analysis (ABA) Treatment Report

PDF Format

Consent to Release Template

PDF Format

Coordination of Care Letter Template

PDF Format

Coordination of Care Form

PDF Format

FEP Outpatient Treatment Report (OTR) Form

PDF Format

Individual Authorization Form

PDF Format

Outpatient Treatment Report – TMS

PDF Format

Provider Profile

PDF Format

Psychological Testing Authorization Form

PDF Format

Psychotherapy Notes Authorization Form

PDF Format

FAQs

Institutional FAQs

PDF Format

Professional FAQs

PDF Format

Quick Guides

Institutional Quick Guide

PDF Format

Professional Quick Guide

PDF Format

 
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