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.  
 

CG-BEH-01 Screening and Testing for Autism Spectrum Disorders and Rett Syndrome

CG-BEH-02 Adaptive Behavioral Treatment for Autism Spectrum Disorder

CG-BEH-03 Psychiatric Disorder Treatment

CG-BEH-04 Substance Abuse Treatment

CG-BEH-05 Eating Disorder Treatment

CG-BEH-07 Psychological Testing

CG-BEH-09 Assertive Community Treatment (ACT)

CG-BEH-10 Basic Skills Training/Social Skills Training

CG-BEH-11 Mental Health Support Services

CG-BEH-12 Psychosocial Rehabilitation Services

CG-BEH-13 Targeted Case Management (TCM)

CG-BEH-14 Intensive In-home Behavioral Health Services

 
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. 
 

BEH.00001 Opioid Antagonists Under Heavy Sedation or General Anesthesia as a Technique of Opioid Detoxification

BEH.00002 Transcranial Magnetic Stimulation

BEH.00004 Activity Therapy for Autism Spectrum Disorders and Rett Syndrome

 

Forms

Applied Behavioral Analysis (ABA) Assessment Request Form for 2015 Dates of Service

PDF Format

Applied Behavioral Analysis (ABA) Treatment Request Form for 2015 Dates of Service

PDF Format

Outpatient Treatment Report (OTR)

PDF Format

Applied Behavioral Analysis (ABA) Treatment Report for 2014 Dates of Service

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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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.