Clinical Review

The following information applies to Preferred Provider Plans, HMSA Commercial HMO plans, Medicare Advantage (PPO/HMO) plans, the Comprehensive Medical Plan, and The HMSA Plan for QUEST Members.

Behavioral Health Intervention and Triage

HMSA assists members who need behavioral health intervention and triage and helps them select an appropriate behavioral health provider. HMO commercial and Medicare Advantage (PPO/HMO) plans do not provide benefits for mental health or substance abuse services rendered by nonparticipating providers.

Concurrent Review

HMSA analyzes claims data for behavioral health and establishes community standards of care for acute inpatient, residential treatment, partial hospitalization, intensive outpatient, and outpatient services. These community standards are used to establish thresholds such as length of stay, which can prompt the need to conduct concurrent review of a case. HMSA then works with the provider to determine whether the ongoing care is appropriate.

Retrospective Review

Retrospective reviews may be conducted after a thorough review of the data indicates that care has exceeded thresholds or community standards of care. An HMSA medical director performs retrospective reviews. Efforts are undertaken to work with practitioners to correct any problem; such efforts may lead to and include recoupment of benefit payment.

Appealing a Concurrent or Retrospective Review

For information, see Concurrent Review or Appealing Processed Claims

Provider Advisory Committee

An advisory committee of behavioral health care providers advises HMSA on mental health and substance abuse issues and clinical protocol. The committee includes psychiatrists, psychologists, other behavioral health providers, and facility representatives.

Case Management Contact Information

Revision History