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 Clinical UM Guidelines can be accessed on the Clinical UM Guidelines main search page. Once the webpage displays, select the tab “By Category,” then the link BEH (Behavioral Health) to view electronic versions of Behavioral Health clinical UM guidelines.  
The Behavioral Health Medical Policies can be accessed on the Medical Policies main search page. Once the webpage displays, select the tab “By Category,” then the link BEH (Behavioral Health) to view electronic versions of Behavioral Health medical policies. 

Forms

Empire BlueCross Behavioral Health Initial Review

PDF Format

Empire BlueCross BlueShield Behavioral Health Initial Review

PDF Format

Empire BlueCross Behavioral Health Concurrent Review

PDF Format

Empire BlueCross BlueShield Behavioral Health Concurrent Review

PDF Format

Empire BlueCross Behavioral Health Neuropsychological Testing

PDF Format

Empire BlueCross BlueShield Behavioral Health Neuropsychological Testing

PDF Format

Empire BlueCross Behavioral Health Electroconvulsive Therapy

PDF Format

Empire BlueCross BlueShield Behavioral Health Electroconvulsive Therapy

PDF Format

Empire BlueCross Behavioral Health Outpatient Treatment

PDF Format

Empire BlueCross BlueShield Behavioral Health Outpatient Treatment

PDF Format

Adaptive Behavioral Treatment Request Form as of 1/1/19 (EBC)

PDF Format

Adaptive Behavioral Treatment Request Form as of 1/1/19 (EBCBS)

PDF Format

Applied Behavioral Analysis (ABA) Assessment Request Form

PDF Format

Applied Behavioral Analysis (ABA) Treatment Request Form

PDF Format

Empire BlueShield Behavioral Health Discharge Note

PDF Format

Empire BlueCross Behavioral Health Discharge Note

PDF Format

Behavioral Health Psychological Testing Request for Authorization

PDF Format

Outpatient Treatment Report (OTR)

PDF Format

Consent to Release Template

PDF Format

Coordination of Care Letter Template

PDF Format

Coordination of Care Form

PDF Format

Federal Employee Program (FEP) ABA Treatment Request 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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Services provided by Empire HealthChoice HMO, Inc. and/or Empire HealthChoice Assurance, Inc., and/or HealthPlus, LLC., licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans, serving residents and businesses in the 28 eastern and southeastern counties of New York State. All external sites will open in a new browser window. Please view our Website Privacy Policy for more information.