Certain services provided by NCWBH require permission before we will cover the costs of those services. The Authorization process allows NCWBH to review the request and supporting documentation before the services are provided to you. This process ensures providers are able to verify Medicaid eligibility and that all services provided meet the criteria for Medical Necessity and DSHS Access to Care Standards (detailed below).
Crisis Services do not require authorization and are available to all individuals in the regional service area.
NCWBH contracts with Behavioral Healthcare Options, Inc. to provide authorizations for outpatient, residential, and inpatient services for all NCWBH providers. They can be contacted toll-free at 1-877-381-3649.
IMD EXCLUSION: Recent changes from the Center for Medicaid and Medicare Services have changed NCWBH’s authorization process for inpatient services (both mental health and substance use disorder treatment). Beginning July 1, 2017, The IMD (Institute for Mental Disease) Exclusion determines that individuals who stay more than 15 days in an IMD Facility (list of IMD facilities) in a calendar month will not be covered by Medicaid for any services for that same calendar month. NCWBH will ensure individuals are able to access necessary services through alternative funding and will monitor inpatient stays through changes in the authorization process. Further guidance on these rules is available here.
When is an authorization required?
When you request services you will complete an assessment or intake evaluation. When it is determined that services are necessary, the NCWBH provider will request the authorization on your behalf. Below is a list of services which require authorization:
- Outpatient mental health services (including Individual and Group treatment for adults, youth, and families)
- WISe and PACT services
- Peer Support services and Day Support for adults
- Psychiatric medication management
- Substance use disorder outpatient treatment
- Substance use disorder residential treatment
- Substance use disorder withdrawal management
- Least Restrictive Alternative Monitoring Services (LRAs)
- Mental health inpatient treatment
What are the authorization requirements?
Individuals seeking the services listed above must meet DSHS Access to Care Standards to be authorized for services (except mental health inpatient treatment, see below). Essentially, individuals must show they are in need of the services due to a mental health or substance use diagnosis and that the services are medically necessary. The full Access to Care Standards, including standards of Medical Necessity, are available here.
Medical necessity for inpatient mental health treatment is assessed by a Designated Mental Health Professional. Additional information is available here.
How will I know if my authorization request has been approved or denied?
If the authorization request is approved, then your provider will be notified that the service can be provided to you. If Behavioral Healthcare Options needs more information in order to approve or deny the request, then your provider will be notified that they need to submit additional information.
If the authorization request is denied, then you will receive a notice .The notice will tell you that the request has been denied, the reason for the denial, and how you can appeal if you disagree.
How can I appeal the denial of an authorization request?
If NCWBH denies your authorization request, then you have the option of appealing through NCWBH’s appeal process. Your denial notice will provide you with information about your appeal options, and the timeline for requesting an appeal.
What if I am already seeing, or wish to see, a behavioral health professional outside of the NCWBH network or from my primary medical provider’s behavioral health services?
Your existing provider may refer you to NCWBH network services to ensure you receive the scope and intensity of services that meet the needs of your diagnosis and presenting concerns. The DSHS Access to Care Standards are designed to determine which individuals will best benefit from the treatment available through the BHO networks. If you are assessed by one of the NCWBH providers and do not meet the Access to Care Standards, you may seek services outside of the network using your Medicaid benefits through your existing medical provider.
If your assessment or course of treatment reveals you are in need of services that cannot be provided by the NCWBH network, you will be assisted in seeking these services from an appropriate professional. NCWBH providers and practitioners value collaboration and will work with your existing or additional providers to ensure you receive the care you need in all areas of health.