Behavioral Health Utilization Management Affirmation Statement

The purpose of the Blue Cross and Blue Shield of Texas (BCBSTX) Behavioral Health Utilization Management (UM) plan is to ensure that members receive medically necessary and appropriate care at the appropriate time and in the appropriate setting.

BCBSTX will help our members access their behavioral health benefits and to improve coordination of care between medical and behavioral health providers. BCBSTX affirms that Utilization Management decisions are based on medical necessity; which includes appropriateness of care and services, and the existence of available benefits. BCBSTX further affirms that:

• The organization does not specifically reward health plan staff, providers and practitioners or other individuals for issuing denials of coverage, care or service.
• Incentive programs are not utilized to encourage decisions that result in under-utilization.
• BCBSTX does not allow decisions in exchange for financial rewards.

Visit the Clinical Resources/Behavioral Health section of the BCBSTX provider website for more information, including the Behavioral Health Medical Necessity Criteria. For additional information, call the Customer Service number on the back of the member’s ID card.