Our behavioral health care team serves to help determine what coverage is provided for

the appropriate level of care and services for our members according to their benefits
plan. We start with a utilization review by a licensed behavioral health provider who can
authorize care or continuation of care. If it is believed that medical necessity for
continued care is no longer met, the case is reviewed by a specialty provider who may
continue to authorize the care or issue a denial if medical necessity for the level of care
is no longer met. If it is believed that medical necessity is no longer being met the
provider requesting the services is offered an opportunity for a peer to peer review prior
to a final medical necessity determination. The review may result in continued
authorization of care or denial if medical necessity is not met.
Please note that for cases involving psychiatric care, the review is done by a boardcertified psychiatrist. For care delivered by a non-psychiatric provider, review may be
done by a psychiatrist or licensed doctoral level psychologist.
In all cases involving an adverse determination the member or provider may request an
appeal that includes a review performed by a like specialty provider not previously
involved in reviewing this case. The review may result in an overturn of the denial with
continued authorization of care or in upholding the denial. In most cases if the denial
was upheld, a members' benefit plan may allow for a review by an independent review
organization (IRO) that involves a like specialty provider not affiliated with BCBSTX. The
determination made by the IRO is binding on the plan.
BCBSTX fully supports mental health parity and designs and implements all members'
benefits accordingly. Our Behavioral Health Division makes medical necessity
determinations in collaboration with the provider, the member and when appropriate,
their family support system. These decisions are based on multiple determinants,
including nationally recognized medical necessity level of care criteria and clinical
practice guidelines, severity of illness, treatment history and clinical response, and
support system at home."
Marina Angelica Coryat
Senior Manager, Media & Community Relations
Southeast Texas Region