Out-of-Network Authorizations for Behavioral Health

Per Medicaid guidelines found in Clinical Coverage Policy 8B, prior authorization is not required for the first 72 hours in an inpatient facility.

Before the ending of the initial 72 hours of service provision, if ongoing services are medically necessary to support the member, the provider should seek prior authorization for services by completing the prior authorization request form and emailing to the Alliance Health Utilization Management (UM) department at [email protected]. The requesting provider should include the initial admission assessment/intake and relevant clinical information to show that ongoing services are medically necessary. A UM clinical specialist will contact the requesting facility to share the outcome of the medical necessity review and discuss the plan of care. All concurrent/continued stay requests should be submitted in the same manner.

Authorization of services does not guarantee payment for services rendered.

Alliance Health makes every effort to first link consumers with network providers, but will consider an out-of-network agreement with an out-of-network provider if a network provider is not available, the service requested is on the posted  Alliance service needs list, or  a network provider is  not accessible to the member.

The provider will submit a Provider Application Request, which will collect information about the provider type, specialties, services requesting to provide, location and information regarding the consumer. Please include any specialty or pertinent information related to request for review and submit the request to [email protected].

Geo-mapping may be completed and provider network or enrollment staff will review the information and will identify if the requested service is on the service needs list or if there is not a network provider that is currently contracted for the service being requested, who meets the 30 mile radius requirement and can provide the approved service. If at least one of these criteria is met, the provider will be offered a member specific out-of-network agreement. If the criteria are not met the provider will be notified that Alliance Health currently has a closed behavioral health network and there are network providers available to provide the service.

If there are no network providers who can provide the approved service within the thirty (30) mile radius, or is on the posted Alliance service needs list, and the treatment is client-specific an out-of-network single client application/agreement will be pursued:

• Provider will submit a provider application request. The request will be reviewed for network need. The provider will be notified if the request is approved to continue with the OON process or if it is denied. Please note all providers need to be enrolled in NCTracks appropriately for the service/site they are requesting.
• If the provider is approved, they will be required to submit an out-of-network prior authorization request form to determine medical necessity for services that require Prior approval.  Please check the Alliance Benefit Plan Service Details to determine if prior approval is needed.  The prior authorization request form will be sent to you by [email protected] once your provider application request is approved.
• The provider will complete and email the out-of-network  prior authorization request form, along with supporting clinical documentation (i.e. comprehensive clinical assessment, person-centered plan, service order) to the Alliance Utilization Management Department at [email protected] within five business days of receiving the OON prior authorization request form.
• UM will review the prior authorization request form for medical necessity. If the UM care manager recommends that the treatment is client-specific and medically necessary, the UM Department will submit the approved prior authorization request form to provider network contracts for the single client application/agreement to be generated. The contract administrator will email the out-of-network single client application/agreement and additional required documents to the out-of-network provider for completion. This will need to be completed and returned to the contract administrator within 14 calendar days to fully execute the agreement and authorization request.

Authorization of services does not guarantee payment for services rendered.