August 2024
Managed Behavioral Health
Provider & Facility Manual
©2024 Lucet. All Rights Reserved.
Contents
Section 1: Introduction ............................................................................................................................ 4
Section 2: Network Operations .............................................................................................................. 10
Section 3: Provider Accessibility............................................................................................................. 17
Section 4: Member Safety and Quality of Care ....................................................................................... 19
Section 5: Managing Utilization ............................................................................................................. 33
Section 6: Clinical Programs ................................................................................................................... 53
Section 7: Clinical Practice Guidelines .................................................................................................... 62
Section 8: Clinical Practice Bulletins ....................................................................................................... 63
Section 9: Fraud, Waste and Abuse ........................................................................................................ 65
Section 10: Billing Assistance ................................................................................................................. 68
Section 11: Compliance Program .......................................................................................................... 75
Section 12: Appendix ............................................................................................................................. 77
Blue Cross Blue Shield of Alabama ......................................................................................................... 78
Arkansas Blue Cross Blue Shield (ABCBS) Commercial HMO and PPO ..................................................... 82
Arkansas Blue Cross Blue Shield (ABCBS) Federal Employee Program (FEP)
(including State of Arkansas Employees) ................................................................................................ 85
Arkansas Blue Cross Blue Shield (ABCBS) Medicare Advantage (MA) ...................................................... 88
Walmart through Arkansas Blue Cross Blue Shield/Blue Advantage Administrators (BAA) ..................... 90
Florida Blue PPO, including Medicare Advantage ................................................................................... 92
Florida Blue HMO, including Medicare Advantage and BlueMedicare Classic Plus HMO, available in
Hillsborough and Palm Beach Counties .................................................................................................. 97
Florida Blue Federal Employee Program (FEP)...................................................................................... 100
Florida Blue Medicare Preferred HMO (Florida Blue and BeHealthy) .................................................... 103
Blue Cross Blue Shield of Kansas (BCBSKS) ........................................................................................... 106
Blue Cross Blue Shield of Kansas City (Blue KC) Blue Care HMO ........................................................... 108
Blue Cross Blue Shield of Kansas City (Blue KC) Medicare ..................................................................... 112
Blue Cross Blue Shield of Kansas City (Blue KC) Preferred Care, Preferred-Care Blue, BlueSelect &
BlueSelect Plus PPO, Affordable Care Act............................................................................................. 114
Blue Cross Blue Shield of Kansas City (Blue KC) Federal Employee Program (FEP)................................. 119
Blue Cross and Blue Shield of Michigan (BCBSM), including United Auto Workers Retiree Medical
Benefits Trust (URMBT), General Motors (GM), and State of Michigan (SOM) ..................................... 122
Blue Cross Blue Shield of Louisiana (BCBSLA) ....................................................................................... 126
SCAN ................................................................................................................................................... 129
Appendix A: Blue Plan Groups ............................................................................................................. 134
Appendix A.1: Tampa General Hospital ................................................................................................ 135
Appendix A.2: Polk County Public Schools ............................................................................................ 136
Appendix B: Medicare Advantage Plans contracted with New Directions ............................................. 137
Appendix B.1: BayCare Select Health Plan............................................................................................ 138
Appendix B.2: Mutual of Omaha Medicare Advantage Company ......................................................... 139
Appendix B.3: Medicare Advantage Insurance Company of Omaha ..................................................... 140
Appendix B.4: Physicians Health Plan (PHP) Medicare ......................................................................... 141
Appendix B.5: Mary Washington Health Plan ....................................................................................... 143
Provider and Facilities Manual
Section 1: Introduction
Preface
Lucet takes pride in the collaborative relationships developed with network providers
and facilities. Our members and your patients/clients gain when we work together to
improve accessibility to the highest quality of care possible at the most affordable cost.
Lucet encourages providers and facilities to give us feedback about
programs, policies, and processes.
Please consider this provider and facility manual as a general guide to
programs, policies, and processes. When updates to the Provider Manual are made,
Lucet makes every effort to communicate these changes to providers and facilities
through email, fax, our website, and our quarterly Provider Newsletter. The current
version of the manual is available on our website at www.lucethealth.com
Providers and facilities are encouraged to contact the Network Operations (Provider
Relations) department at providerrelations@lucethealth.com with questions and issues
not covered here or to clarify any content. To notify Lucet of updates to your practice
locations, demographics, and new areas of clinical specialization, please go to the
Profile update form available on our website at www.lucethealth.com. To discuss other
matters, providers may also call 1-888-611-6285.
About Lucet
Expectations of Providers
We appreciate your hard work and dedication to empower members to live life to the
fullest. Our goal in working with our provider community is to continuously improve the
care delivery system within each of our networks from region to region. We strongly
believe that we can only do so through continuing to strengthen our collaborative
working relationships with providers who use evidence-based practices with fidelity to
the model and whose clinical outcomes for members support their recovery of health
and life roles. The success of these efforts will be demonstrated by our ability to work
with our network to achieve the Triple Aim of improved health, reduced cost, and better
member experience.
This manual is a valuable resource that describes our commitment, expectations, and
services to support your success in delivering care to members. Please refer to our
delivery of care expectations below and our supportive resources described in the
Clinical Program section.
Delivery of Care Expectations and Supportive Resources
1. Delivery of care in the least restrictive setting
Providing the least restrictive setting is especially important when
members are being evaluated for higher levels of treatment. The level of
intensity of services will need to match the member’s clinical needs. We
prefer that members be treated as close to their homes as possible to
help ensure community-based resources are in place to support better
outcomes over a longer period.
2. Setting clear and measurable goals
We believe more treatment does not necessarily mean better treatment. It
is the provider’s responsibility to establish key treatment milestones with
clear and measurable goals to understand progress and objectively
determine when a member has successfully completed treatment.
Treatment must answer the questions, “Why is this level of care needed
now?” “What measurable outcomes will be used to define success?”
3. Improved member engagement
Make use of the Lucet Care Management team (see Section 6) to help
members safely discharge to the community and have a comprehensive
community-based treatment plan. We expect providers to obtain a
Release of Information (ROI) from the member before discharge, as it
enables Lucet to coordinate care and facilitate access to other types of
clinical resources, including support groups, self-management resources,
and assistance in addressing barriers to care. The ROI is essential
because it allows these resources to work directly with the patient and
family members.
4. Discharge planning
Discharge planning is a critical component of quality member care that
begins on the day of admission. Quality discharge
planning includes coordination and linkage to applicable behavioral
health, medical, legal, and social determinant follow-up resources. Lucet
expects comprehensive discharge planning that integrates elements of
IDEAL Discharge Planning as published by the Agency for Healthcare
Research and Quality. Guidelines summarizing best practices of IDEAL
Discharge Planning should be reviewed at www.ahrq.gov. A facility’s
performance is evaluated on the percentage of members attending follow-
up visits, readmission rates, and other key indicators. Discharge planning
is critical to that progress. All facility-based care providers are required to
submit quality discharge plans to Lucet within forty-eight hours of
discharge or change in service level. Quality
Discharge plans must include documentation of the following:
• A scheduled discharge appointment within seven days of
discharge. For mental health admissions, follow-up
appointments should meet the defined criteria for HEDIS.
• Member understanding of discharge plans, including knowledge
of discharge appointments and aftercare goals
• Member involvement in discharge decision-making
• A current crisis/safety/relapse prevention plan
5. A signed Authorized Designee / Authorization of Representation Form
Lucet shall monitor and inform the facility of de-identified scorecard
information to evaluate their performance of quality discharge metrics.
Lucet shall provide the provider with the performance data and analysis
and allow the opportunity to discuss findings. The provider is expected to
review scorecard metrics and work cooperatively with Lucet to improve
quality discharge performance. For more information on the specific form
items, please visit the Clinical Discharge Form Flyer and Clinical
Discharge Review Form.
6. Scheduling a 7-day follow-up appointment after mental health inpatient
discharge
After an inpatient discharge, members should follow up with a licensed
clinician within seven days. When coordinating 7-day follow-up
appointments, providers must verify the patient’s availability for the
appointment. Lucet can assist in identifying providers who can offer
appointments within seven (7) days. To request assistance in identifying a
provider who can see a member within seven (7) days, contact Lucet at
the phone number on the insurance card.
7. Community-based resources
Utilize community-based resources to address social determinants of
health while providing longer-term stability and independence. Lucet can
assist you with our sophisticated resource database to identify resources
such as food pantries, domestic abuse shelters, energy assistance, job
training, and support groups, among many others.
8. Integration with physical health
Coordinating care with the patient’s primary care physician (PCP) will
create a holistic care plan to address comorbidity and allow the PCP to
communicate and receive valuable information about the member’s
physical and behavioral.
9. Provider Performance
Lucet is committed to promoting a high-quality network of providers
available to members. Consistent with the triple aim of healthcare,
provider performance will be monitored to evaluate improved member
health, reduced cost, and a better member experience. Measurements
differ based on the level of care being provided, emphasizing metrics that
promote quality outcomes such as readmission rate and timely access to
treatment.
10. Clinical record documentation
Documentation must be clear and support the claims billed and/or
services that meet medical necessity criteria for ongoing treatment.
The medical record must include documentation of the active participation
of the member in treatment and progress toward goals achieved.
11. Measure outcomes
Lucet may conduct provider profiling using claims-based analysis that
enables us to understand network quality and cost performance at the
individual provider and facility level. This allows us to guide members to
top-performing providers who meet member needs in terms of service,
cultural attributes, and accessibility factors.
12. Member Experience
Lucet partners with providers to ensure members get the care they need
at the right time with the right provider. We understand that members
seeking services are often at their most vulnerable. Caring for
them with dignity, respect, and a spirit of collaboration contributes to a
positive outcome.
Lucet expects providers to:
• Provide considerate, courteous care, treat members with respect, and
recognize personal privacy, dignity, and confidentiality.
• Have a candid discussion of medically necessary and appropriate
treatment options or services for each member's condition regardless
of cost or benefit.
• Deliver information in clear and understandable terms.
• Provide culturally sensitive care, including respecting members'
cultural, racial, ethnic, and linguistic needs.
• Engage members in treatment planning and treatment decisions
and verify members understand the treatment plan.
• Discuss medical records with members and keep health
records confidential except when disclosure is required or permitted by
law.
• Communicate effectively by returning messages within 24 hours and
setting clear expectations with members regarding appointment
availability.
• Respond to questions concerning treatment sufficiently to address
member’s issues.
• Explain the cost of treatment fully when members inquire. Provide
Lucet with accurate information regarding demographics, discipline,
specialty, and office hours to ensure members have accurate
information.
• Assist members needing services and care that cannot be
accommodated by clearly redirecting back to Lucet for assistance.
Together is the way forward. By collaborating, we can achieve more on the patient’s
behalf. When you need additional support, Lucet offers innovative resources to help
support your success, such as on-site care management, on-site care transitions, an
enhanced network of outpatient providers who can see members within Seven (7) days
of discharge, in-home behavioral health services, coordination of medication delivery
on the day of discharge, and coordination of medication compliance follow-up, among
other services (services are not available in all locales). Email Lucet Provider Relations
at ProviderRelations@lucethealth.com to learn about the resources available in your
area.
Provider Communications
Lucet updates the manual annually and as needed. The updated version is available
online at www.lucethealth.com. Throughout the year, we convey policy changes and
other pertinent information to Providers and Facilities through various channels:
• Newsletters
• Broadcast emails
• Office manager meetings
• Website at www.lucethealth.com
• Educational workshops and symposiums
Please ensure your email address, office location, and practice information is up-to-
date by reviewing your provider directory information in the Provider Update
Form. Remember, as a participating provider in the Lucet network, you are required to
notify us within 72 hours if you have a change of address, phone number, fax
number, or email. Lucet will ask you to verify the accuracy of your provider directory
information every 90 days. You are required to attest to its accuracy or update your
profile to make it accurate.
Contacting Lucet
To contact the Lucet Service Center for utilization management, care management,
care consultation, or administrative questions regarding eligibility, benefits, or claims,
please refer to health and group plan-specific information in the appendix at the end of
this manual.
Website
Lucet provides detailed and easy-to-use information about many programs and
services at www.lucethealth.com. Updates occur frequently to provide current
information about behavioral health care and services. The website includes the
following:
• Lucet Provider and Facility Manual
• Documentation forms
• Lucet Medical Necessity Criteria for authorization of payment determinations
• Medical Policy for TMS
• Lucet Applied Behavior Analysis for the Treatment of Autism Spectrum Disorder
Medical Policy
• Clinical Practice Guidelines
• Provider WebPass (username and password are needed)
• Eligibility information for many Lucet contracts
• Benefit information for many Lucet contracts
• Notice of Privacy Practices for Lucet
• Member rights and responsibilities
• Information about our Quality and Care Management programs
• An Autism Resource Center for parents/caregivers of a child with an autism
spectrum disorder
• A Substance Use Disorder Center to assist members and families struggling with
alcohol misuse or dependency.
The website also includes a provider search feature, allowing our members to locate
Providers by name, location, and specialization. Members can also filter their searches
by gender, language, age group, ethnic origin, credential/discipline, and whether
providers are accepting new patients.
“WebPass”
Providers utilize Lucet’s “WebPass” system to check member eligibility and benefits,
request authorizations, and check the status of authorization requests.
prwebpass@ndbh.com Before using the WebPass system, you must obtain a username
and password from Lucet. Please click here to access the form to request a WebPass
account.
Lucet expects providers to learn and understand the WebPass system as the primary
means to interface with Lucet. Please submit authorization requests and check the
status of authorizations through WebPass. Please review the WebPass section under
Section 2: Network Operations.
Network Reports
Please be aware that you or your patients may be selected to complete a survey
about their Lucet experience.
Lucet conducts several surveys to assess quality and direct quality improvement
initiatives, including an annual Member Satisfaction Survey, Provider Satisfaction
survey, and surveys to evaluate geographical availability and access to appointments.
In addition, Lucet may conduct spot surveys to assess specific tools or processes to
gather provider input into significant changes under consideration.
Section 2: Network Operations
Policies and Procedures
Pursuant to the terms of the Provider/Facility Agreement, providers and facilities must
comply with Lucet policies and this manual. Certain policies may apply to only a
designated line of business, type of benefit plan, or government-sponsored health
benefits program. You may find select policies and procedures on the provider portal at
https://providerportal.lucethealth.com/s/login/ or on our out-of-network resource page at
https://lucethealth.com/providers/outside-network/
Change in Provider Demographics
Providers must notify Lucet of any changes to availability or demographics, including
email addresses. Refer to the appendix below to determine the notification deadlines
that apply to you. Providers must review and attest to the accuracy
of their demographics every 90 days to ensure they are accurate, up-to-date, and in
compliance with their obligations under The Consolidated Appropriations Act of 2021.
Demographic changes can be made through the provider portal at
https://providerportal.lucethealth.com/s/login/
Note: Any address or Tax ID number updates/changes require a current W-9 form.
If you have questions, please get in touch with Provider Relations at 888-611-6285 or submit
providerrelations@lucethealth.com a service ticket on the
provider portal at
https://providerportal.lucethealth.com/s/login.
Groups and Facilities must notify Lucet of any changes to employee rosters within 72
hours. Follow the link and directions provided above to submit these changes.
Credentialing Criteria
Lucet credentials and re-credentials providers and facilities in compliance with NCQA
accreditation standards, applicable health plan policies, and applicable state and federal
laws. The Lucet Credentialing Committee makes decisions regarding credentialing and
re-credentialing.
Minimum criteria for consideration as a provider in the Lucet network must include:
• Current unrestricted state professional license(s) or registration(s) that authorizes
the applicant to practice independently in the state(s) where services
are provided
• For facilities, PHP, IOP, and CMHC programs, an active unrestricted license for
the services seeking to be contracted
• Minimum practice of fifteen hours per week
• An acceptable level of professional liability insurance (preferred coverage is
$1,000,000 occurrence/$3,000,000 aggregate but may vary according to state
law or Plan requirements)
• Internet access
• Up-to-date mailing address and email address
• Have 24-hour phone coverage
M.D. and D.O. Eligibility Requirements
M.D. and D.O. applicants must meet eligibility requirements in one of the following
ways:
1. The M.D. or D.O. applicant has obtained board certification through the American
Board of Medical Specialties (ABMS) or the American Osteopathic Association
(AOA) in Psychiatry by the ABMS/AOA certifying Member Board, a M.D. or D.O.
applicants with recent completion of their psychiatry residency may apply to the
network with the requirement they shall become board-certified within one of the
following two consecutive testing periods following the completion of their
residency (e.g., residency completed June 2022, first testing period September
2022, second testing period September 2023, terminate November 2023 if not
board certified). If board certification is not obtained during this time frame, the
M.D. or D.O. credentials and, as a result, the provider contract will terminate at
the end of November of the year following the second testing period or
2. The M.D. or D.O. applicant has obtained Board Certification through the ABMS
or AOA in Addiction Medicine by ABMS/AOA certifying Member Boards or a non-
expired certification from the American Board of Addiction Medicine (ABAM) and
intends to treat individuals with substance use disorders. In addition, this
category of M.D. and D.O. applicants must be board-certified by the ABMS or the
AOA in the area in which they completed their residency. This type of physician
will be referred to as an Addiction Medicine Specialist.
Site Visits
Lucet may conduct a site visit of network provider facilities and/or offices.
Site visits may include a review of any or all of the following:
• Availability and access to services
• Physical plant safety & environment
• Adherence to HIPAA and confidentiality
• ADA Compliance
• Patient Rights and Responsibilities
• Treatment recordkeeping and maintenance practices
• Member record documentation
• Medication safety
• H.R. practices, including credential verification of licensed staff, training and hiring
practices of direct care staff
• Quality of services provided to members
• Quality & Risk Management processes and improvement programs
• Member treatment program philosophy
• Other
Board Certified Behavior Analyst (BCBA)
Line Therapists are Registered Behavior Technicians (RBT) certified or Board Certified
Assistant Behavior Analysts (BCaBA) via the Behavior Analyst Certification Board
(BACB). It is the duty and responsibility of the supervising Board Certified Behavior
Analyst (BCBA) to ensure compliance with the following requirements in the line of
therapists you supervise.
Line therapists you supervise must be made aware in writing that they must inform you
within 72 hours if they are arrested, or a criminal action is brought against them. If the
arrest/criminal action involves violence, dishonesty, or sexual activity involving a minor,
the line therapist will not be permitted to work with any member until either the charges
brought against the individual are dropped or until a court of competent jurisdiction
adjudicates the individual as not guilty of the charges underlying the arrest or the
criminal action.
A national criminal background check must be conducted for all Line Therapists,
containing a search of the National Sex Offender Registry. Line Therapists must also be
covered under the Supervising BCBA and Employers professional liability insurance
with at least $1,000,000 per occurrence and $3,000,000 aggregate.
Provider Rights and Responsibilities
Providers have the right to:
1. Access information contained in personal credentials files
2. Rectify erroneous information in personal credentials files
3. Be informed of their status in the credentialing/re-credentialing process
4. Request a hearing in accordance with the Fair Hearing Plan policy if an adverse
recommendation by the Credentialing Committee regarding participation in the
Lucet network is made
5. Be credentialed in accordance with the Provider Credentialing and Re-
credentialing policy, which describes the processes for credentialing and re-
credentialing, including:
• Maintaining the confidentiality of the credentials files to the extent permitted
under state or federal laws and Lucet policies
• Credentialing and re-credentialing recommendations that are non-
discriminatory
• Right to be notified if information received during the credentialing/re-
credentialing process is substantially different from information received from
a Provider
• Notification within ten (10) business days of initial credentialing and adverse
re-credentialing decisions.
Providers have the responsibility to:
1. Use and disclose protected health information in accordance with federal and
applicable state laws
2. Comply with Lucet and the applicable plan’s credentialing, quality management,
member grievance, care transitions, performance evaluation, disciplinary process,
utilization review, care management, and disease management programs
3. Comply with Lucet and the applicable plan’s claims submission and
processing requirements
4. Maintain health information (treatment records); submit to reasonably requested
audits; implement action plans as required; and participate in follow-up reviews
of deficiencies
5. Obtain Release of Information (ROIs) and other consents required to enable
coordination of care, care management, and claims resolution activities by Lucet
and the member’s plan
6. Communicate with primary care physicians and other providers about
mutual members
7. Comply with billing rules and guidelines
8. Coordinate care with other in-network health care providers whenever possible
and appropriate
9. Use the WebPass system to:
• check member eligibility and benefits
• request authorizations
• Check authorization status (Authorization notices are mailed to providers)
• Submit Discharge information within 48 hours of discharge
10. Review and update their provider demographics at least every 90 days
Provider WebPass
WebPass is for providers and facilities to check member eligibility and plan benefits,
request authorizations, and review the status of authorization requests. You will find
membership eligibility and plan benefits in the provider WebPass section.
Web-based online support via the Internet: Lucet’s online WebPass system is a
password-protected website that allows providers to request and verify member
authorizations 24/7/365, communicate discharge information, and submit care
management referrals. The WebPass system provides users a safe and secure way to
send protected health information to Lucet.
Getting Started with WebPass
To create a new WebPass account, a provider or facility can email Lucet the request.
The email must include the Tax ID and the WebPass user’s first name, last name, and
email address.
For entities with multiple users under one Tax ID, the user may request an
administrator role. The administrator will manage additional WebPass users with that
Tax ID, including adding users, resetting passwords, and deleting users who are no
longer authorized to access the WebPass account.
Training resources for WebPass are located on the WebPass Login Page at:
https://webpass.ndbh.com/.
Training guides for the Authorization Forms are located at:
https://lucethealth.com/providers/outside-network/. Select your health plan and choose
Provider Resources.
Troubleshooting & Common Issues with Logging in to a Webpass
Account
If you need to reset your password, please go to https://webpass.ndbh.com/ and click the
“Forgot Password” link to generate a new temporary password. The temporary
password is only active for 24 hours. If 24 hours elapse without setting up a permanent
password, a new temporary password must be requested by clicking the “Forgot
Password” link again. If you continue to experience issues logging in to your account,
please email us at prwebpass@ndbh.com
If your organization has multiple Tax IDs, you must have a separate account for each
Tax ID.
You must log in every 180 days, or your WebPass account will be locked for security
reasons.
You must update your demographic information with Lucet before it will be displayed in
the WebPass system. Links to submit demographic changes are available on the
WebPass login page or at www.lucethealth.com
If you experience problems with obtaining timely eligibility and benefits information,
please get in touch with us by emailing prwebpass@ndbh.com
WebPass Reminders
Urgent care coverage review schedule - Lucet will complete continued stay and
step-down reviews for urgent care on the last covered day. Please submit
continued stay and step-down review requests for inpatient and residential on the
last authorized day.
[Ex., Lucet authorizes urgent care coverage for 11/27-11/29. We will review
continued or step-down requests on 11/28. Provider should, therefore, submit a
review request on 11/28 because it is the last covered day. Remember that the
day of discharge is not covered. In this example, 11/29 is the day of discharge.]
• Timely submissions – For inpatient or residential care members, please submit
continued stay review requests and step-down review requests before 12:30 p.m.
EST. Again, reviews should be submitted on the last covered day. Doing so
enables Lucet to provide a timely and complete medical necessity determination,
allowing for peer reviews if needed.
• Diagnosis – Please provide the most accurate diagnosis and update in
each WebPass submission as reflected in the medical record.
• Continued stay requests – Updated clinical information is required to reflect the
member’s current status and progress on measurable goals, as listed on the
member’s individualized treatment plan.
• Progress – As indicated, please provide CIWA scores, vitals, and labs. Include
the most recent results.
• Medications – Medications must be updated in each submission.
• Discharge plan – Please ensure a discharge plan is populated on the initial
authorization request and updated with each concurrent authorization review
request, including specific providers and appointments. All facility-based care
providers are required to submit a WebPass Discharge Form to Lucet for all levels
of care within 48 hours of discharge or change in service level. Members require
follow-up appointments within seven (7) days of discharge. For mental health
admissions, follow-up appointments should meet the defined criteria for HEDIS.
• Forms – Please submit all needed forms, including releases of information,
member consent for referral to Behavioral Health Homes (BHH), consent for
referral to other providers to coordinate care, and the Medicare Important
Message Form.
• To View the WebPass request authorization decision:
o Log in to WebPass
o Complete a” Member Search”
o Click “Member Authorizations Viewer” in the function menu
o Click “Details” on the left side of the authorization. A new window will
be generated that has the authorization details, including the
decision.
Section 3: Provider Accessibility
Overview
Lucet is committed to assisting members to obtain timely access to services with
appropriate network providers. When members contact Lucet and request assistance in
finding a provider for a routine referral, Lucet attempts to directly schedule with the
provider or provide the name and contact information for 3-5 providers. For members
contacting Lucet with urgent needs, Lucet links the member with the provider and sets
up the appointment.
Availability Standards
Lucet requests that providers make every effort to provide timely access to members
according to their needs.
Urgent or Emergent Care
In an urgent or emergent situation, the member must be offered the opportunity to be
seen in person immediately. If a member contacts your office with an urgent or
emergent situation, and your office cannot provide an appointment within the
timeframes below as appropriate based on the member’s clinical situation, your office
should refer the member to an emergency room.
• Immediately is further defined as:
o Life-Threatening Emergency: In a life-threatening emergency, the member
should be seen as soon as possible, within an hour.
o Non-life-Threatening Emergency: When there is a significant risk of
serious deterioration, the member must be seen within 6 hours of the
request.
o Urgent: In an urgent situation, the member must be offered the opportunity
to be seen within twenty-four (24) hours of the request.
Non-Urgent with Attention Required
If the member’s needs are not urgent but delays in access to medical attention could be
detrimental, the member must be offered the opportunity to be seen within seven (7)
days of the request.
Routine Office Visit – Initial
For a member whose circumstances are non-urgent and do not require medical
attention, the member must be offered an appointment within ten (10) days of request.
Routine Office Visit -Follow-Up
For a routine office visit that is considered a follow-up visit, the member must be offered
the opportunity to be seen within thirty (30) days of the request.
Coordination of Care with Primary Care Physicians and other
Providers
Lucet encourages all providers to coordinate and share information with their patients’
primary care physicians (PCP) and other behavioral and medical specialists (e.g.,
neurologists, pain management, etc.) whenever appropriate. Lucet actively participates
in these collaborative efforts. You may be contacted by a Lucet staff member to assist
you in scheduling an appointment, verifying attendance, treatment planning, medication
reconciliation, completing an authorization form, and other efforts to coordinate care.
To facilitate care coordination, Lucet provides several authorization forms on our
website for your use.
Members benefit when all healthcare providers share health information. Lucet
recommends that network providers educate and explain to members the important
reasons for sharing health information with their PCP and other health care
providers.
Authorization from a member may be required when sharing health information with
other treating healthcare providers or with Lucet. Such activity may fall under the
treatment, payment, and healthcare operations exceptions under HIPAA, which allows
information to be shared without a release in many situations. Heightened
requirements exist for substance use disorder information under 42 CFR Part 2,
and some state laws specific to mental health or substance use clinical information are
more restrictive than HIPAA. Psychotherapy notes, identifying information related to
HIV/AIDS, and genetic information are also subject to more stringent requirements.
Providers must comply with relevant federal and state laws regarding contact with other
healthcare providers.
To promote better outcomes and whole-person treatment, providers are encouraged to
educate their patients on the benefits of coordinated care and request authorization to
release information when applicable and appropriate. We encourage all providers to
participate in these collaborative efforts to ensure the best possible outcomes for
members.
Section 4: Member Safety and Quality of Care
Member and Client Rights and Responsibilities
Members/Clients have the right to:
1. Receive information about Lucet, its services, its network providers and affiliates,
and their rights and responsibilities.
2. Be treated with respect and receive recognition of their dignity and right to
privacy.
3. Receive communications in a language they understand.
4. Participate with network providers and affiliates in decisions about their health
care.
5. Have a candid discussion of appropriate or medically necessary treatment
options for their health conditions, regardless of cost or benefit coverage.
6. Voice complaints or appeals about Lucet or the services or care they receive
either verbally or in writing and obtain prompt resolution.
7. Make recommendations regarding this Statement of Rights and Responsibilities
for members and clients.
8. Expect confidentiality of their personal health information
9. Inspect and copy their personal health information.
10. Be ensured reasonable access to care without discrimination.
11. Include family/significant others in health care decision-making and treatment
planning.
12. Treatment that is individualized and offers interventions and options that are
customized, flexible, and adapted to meet member’s unique needs.
13. Receive information and explanation about the guidelines and criteria used in
making medical necessity decisions.
14. Expect Lucet to advocate on the member’s behalf (if asked).
15. Be provided information regarding staff, network, or vendor qualifications of
organizations contracted by Lucet to provide services.
16. Decline to participate in programs or services or to withdraw from programs or
services at their will.
17. Be provided with information regarding the staff members that manage their
services and how they can request to change services.
Members/Clients accept the responsibility to:
1. Provide information (to the extent possible) that Lucet and its providers and
affiliates need to support health care.
2. Follow the plans and the instructions for care and treatment agreed upon with
plans, providers, and affiliates.
3. Understand their health conditions and participate in developing mutually agreed-
upon treatment goals, to the extent possible
4. Inform their provider or Lucet of their decision to decline or withdraw from a care
management program.
Quality Improvement
Lucet establishes and maintains the Quality Improvement (QI) Program, which is
designed to continuously improve the quality of behavioral health care and service
provided to our members. QI initiatives strive to achieve significant improvement in
identified clinical and non-clinical service areas and are expected to have a positive
impact on health outcomes, services received, and member and provider satisfaction
over time.
Data collected for QI projects and activities are related to key indicators of clinical care
and service that focus on high-volume and high-risk diagnoses, services, or
populations. Goals are established, measured, and analyzed; many of which are based
on those established by national accrediting organizations and best practices. The QI
Program is intended to ensure that the structure and processes in place lead to desired
outcomes for both members and providers.
The scope of the Lucet QI Program includes:
• Member safety
• Treatment services
• Treatment outcome
• Access and availability of care
• Continuity and coordination of care
• Cultural and linguistic needs
• Care Management services
• Complaints
• Member and provider satisfaction
• Confidentiality and privacy
Lucet evaluates its QI Program annually. Based on the results, a new work plan is
created for the following year. Further information about the Quality Improvement
Program is available on request by emailing QualityImprovement@lucethealth.com
Population Diversity and Health Equity
Lucet is focused on providing and coordinating care for the whole person. This whole
person approach is inclusive of the individual and unique needs of the member.
Understanding these factors improves communication to help better address challenges
and quickly connect members to providers who can meet their needs.
Diversity and health equity factors and/or preferences include:
• Spoken language(s)
• Customs
• Beliefs
• Values
• Gender
• Ethnicity
• Racial
• Social
• Religious and Spiritual
• Disabilities such as hearing, vision, or mobility impairment
Lucet members voice their disparity concerns through member satisfaction surveys and
the complaints or grievances processes. The information provides Lucet approach to
strategically use cultural competency as a valuable adjunct to the quality improvement
process. This process identifies opportunities to assess network structure, recognize
training and hiring needs, facilitate learning between providers and members and
provide firsthand feedback to providers to improve health equity, resulting in enhanced
member experience.
Lucet’s influence on positive change is not only external to our members and providers,
but internally with our own staff. Cultivating cultural behaviors internally helps with Lucet
service delivery to our diverse member populations and enables staff to work effectively
cross-culturally. An internal Diversity, Equity and Inclusion Committee facilitates the
following functions.
• Institutionalizing cultural knowledge
• Promoting education and collaboration on diverse viewpoints
• Supporting programs that strengthen and foster an inclusive work environment.
Integrating the knowledge of the member’s cultural, language, and impairment needs
into provider practices and applying it appropriately to meet the member’s disparity
needs will help build the bridge between the member and their provider.
Acknowledging members’ cultural needs, preferences, beliefs, and values is recognizing
their personal identity and key to establishing a trusting relationship and developing a
suitable treatment plan. Since 1979, The U.S Department of Health and Human
Services’ Office of Disease Prevention and Health Promotion has set priorities for
preventing disease and promoting the health of all Americans with Healthy People
initiatives. An overarching goal of “Healthy People 2020” is to achieve health equity and
eliminate health disparities. Health disparities are differences in health outcomes and
their causes among groups of people. Reducing health disparities creates better health
for all Americans.
With appropriate resources in place, members of diverse populations
can be treated effectively. A provider’s sensitivity to cultural factors may directly shape a
member’s experience and their ability to participate in their treatment. It can also
enhance delivery of health care services for members with these special requirements.
How can you meet members’ unique needs?
• Maintain current and complete information of your outward facing demographics
to assist in matching a member’s preference for a provider. Doing this creates a
better fit for you and the member. To update your demographics, please submit
information via the Provider Update form or by contacting
providerrelations@lucethealth.com
• In addition, ensure you and your staff are sensitive to cultural and linguistic
aspects in your treatment services. The links below offer additional information
from the Agency for Healthcare Research and Quality and the Health Resources
and Services Administration websites.
Helpful Links
Healthy People 2020: https://www.healthypeople.gov/2020/About-Healthy-People
Address Language Differences
https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-
safety/quality-resources/tools/literacy-toolkit/healthlittoolkit2_tool9.pdf
Religion, culture, beliefs, and ethnic customs
https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-
safety/quality-resources/tools/literacy-toolkit/healthlittoolkit2_tool10.pdf
The Culture, Language, and Health Literacy Overview video
http://www.hrsa.gov/culturalcompetence/index.html
Utilization Management (UM) Services
The UM program promotes positive health outcomes by providing the structure and
processes needed to provide care management for Managed Behavioral Health
(MBH) members. Lucet’s care and utilization management approach aims to align
attention and resources to address:
• The care needs of members with clinical complexities, requiring high levels of
health care services
• Needs of members in populations requiring specialty care
• The need for evidence-based care for all members, including newly diagnosed or
first presenting
• Transitions of care, so that members experience continuity of care as they move
through the behavioral health/substance use disorder continuum of services.
• The UM Program is a framework for making benefit determinations affecting the
health care of members in a fair, impartial, and consistent manner. All
UM services are provided by phone or through Lucet’s website
(www.lucethealth.com)
The UM staff is available 24/7 to provide information about UM processes and to
address requests for benefit coverage. Members have direct access to all behavioral
health providers and can self‐refer to providers for assessment. Members who contact
Lucet for assistance to find a provider and obtain an appointment are asked a series of
questions. These questions enable UM staff to determine the type of services needed,
the acuity of the member’s condition, and the appropriate time frame for the
appointment. In urgent and emergent situations, the member is assisted with access to
services. The safety of the member is the primary concern. The staff facilitates peer
clinical reviews, appeals and coordinates services with other departments.
Focus Areas
As part of our Quality Improvement program, Lucet focuses on key activities to support
member safety, experience, and outcomes. A sample of some of these key activities which we
monitor and emphasize both internally and with our providers include:
Member Safety - Lucet promotes the exchange of information between medical and
behavioral health providers. Communication with providers about key elements
associated with member care improves member safety, continuity of care and
coordination of care.
Medication Safety - Identifying opportunities for medication reconciliation is one of the
key elements of coordination of care activities. When members participate in our Care
Management (CM) program, Lucet provides a list of the medications reported by
the member or from facility discharge orders to their prescribing physicians. This
enables the prescribing physicians to review the medication list and identify and
reconcile any discrepancies. Lucet’s care managers utilize our Coordination of Care fax
form (COC Form) to communicate with medical and behavioral health providers to
facilitate medication reconciliation. By informing ordering providers of the need for
medication reconciliation, actions can be taken to reduce inconsistencies, decrease the
potential for harm and provide a channel to communicate a list of members’ prescribed
medications to medical and behavioral health providers.
Medication Overdose – Studies show that suicide attempt by overdose is associated
with high personal and social costs along with a high rate of repeated admissions. Lucet
designed a Medication Overdose Prevention Program to decrease the potential for
recurrent prescribed medication overdose among members hospitalized for psychiatric
and/or substance use treatment. When Lucet’s care managers learn that a member is
hospitalized for a suicide attempt by overdosing with prescribed medications, they notify
the prescribing physician prior to member discharge. Physicians can then determine if a
change in prescription is needed.
Quality of Care – Lucet strives to develop, maintain and promote best practices in
behavioral health care. Our focus is on defining and measuring quality.
HEDIS Performance Measure Monitoring - HEDIS (Health Care Effectiveness Data
and Information Set) measures are tools used to gauge performance on
important dimensions of care and service. The following measures, monitored by Lucet,
involve providers’ implementation of best practices in managing their patients’
behavioral health care.
• Antidepressant Medication Management – Studies indicate that nearly half of all
patients who begin antidepressant treatment discontinue medications within the first
90 days of being prescribed medications, while half the remaining patients
discontinue medications during the continuation phase, which includes the initial 180
days. Lucet monitors members 18 years and older with a diagnosis of major
depression who have been treated with antidepressant medication, for their
continued use of the medication at 84 days (acute phase) and 180 days
(continuation phase).
• Follow-up Care for Children Prescribed ADHD Medication - Stimulant dosing is
typically adjusted on a weekly basis and initial follow up monthly is recommended.
Once medication dosing is stable, clinical follow up appointments can be spaced to
every 3 months for the first year. In children with long-term stability, follow-up visits
every 6 months can be considered. (2017, Translational Pediatrics)
• Follow‐Up after Hospitalization for Mental Illness – Timely follow-up after
hospitalization promotes continuity of care and reduces the likelihood of
rehospitalization. Lucet assists members in receiving timely outpatient behavioral
health services following a discharge from an in-patient behavioral health admission.
Members, 6 years of age and older, who were hospitalized for treatment of selected
mental illness diagnoses, are monitored for completion of an outpatient visit,
intensive outpatient encounter or partial hospitalization encounter within 7 days and
30 days of discharge.
• Diabetes Screening for People with Schizophrenia or Bipolar Disorder Who are
Using Antipsychotic Medications – People with schizophrenia and bipolar
disorder are at a greater risk of metabolic syndrome due to their serious mental
illness. Diabetes screening for individuals with schizophrenia or bipolar disorder and
who are prescribed an antipsychotic medication may lead to earlier identification and
subsequent treatment of diabetes. Members 18-64 years of age with schizophrenia,
or bipolar disorder, and who were dispensed an antipsychotic medication are
monitored to determine if they have had a diabetes screening test during the year.
• Initiation and Engagement of Alcohol and Other Drug Dependence Treatment
– Studies have identified the need to quickly engage members in follow-up treatment
after they have been diagnosed with a substance use disorder. Lucet
monitors members, ages 13 years and older, with newly diagnosed alcohol and drug
dependence, to ensure that treatment was initiated within 14 days of the diagnosis.
The measure also reflects the percentage of members who meet these criteria and
who are engaged in two or more additional services within 30 days of the initiation
visit to evaluate ongoing treatment engagement.
• Readmissions – Discharge from an inpatient setting is a critical transition point
in a member’s care. Lucet, in conjunction with health plans, monitors the number of
adult acute inpatient stays that were followed by an acute readmission within 30
days. The measure is used, in part to identify additional discharge planning needs
for the member who readmits, to identify facility trends and identify potential gaps in
discharge resources. Both behavioral health and medical admissions are considered
in this annual HEDIS measure.
• Adherence to Antipsychotic Medications for Individuals with
Schizophrenia– For members with schizophrenia, lack of adherence to treatment
with antipsychotics is common, and can be a significant cause of relapse. Lucet
monitors the percentage of adult members with schizophrenia who were dispensed
and remained on an antipsychotic medication for at least 80 percent of their
treatment period.
o Monitoring antipsychotic medication adherence may lead to a reduced
rate of relapse and fewer hospitalizations.
Lucet screening programs are designed to provide early identification of potential
disorders and assist providers as they direct members to appropriate assessments and
levels of care to avoid complications of untreated conditions.
• The Behavioral Health Screening for Coexisting Depression and
Substance Use program aims to detect depression in members admitted to a higher
level of care for substance use disorder. Lucet utilizes WebPass and telephonic
utilization management contacts to collect information as to whether a depression
screen was performed, and if the result was positive during all admissions for a
substance use disorder. If left unidentified and untreated, the coexistence of
substance use, and depression can complicate treatment of the member and can
hinder providers’ efforts to address the member’s substance use disorder. This
comorbidity places individuals at high risk for suicide and social and personal
impairment.
• The Behavioral Health Screening for Diabetes Screening for People with
Schizophrenia or Bipolar Disorder Who are Using Antipsychotic Medications is
a program based on scientific evidence that, in patients diagnosed with schizophrenia
or bipolar disorder, a strong correlation exists between the prescription of
antipsychotic medications and the occurrence of diabetes. Members with bipolar
disorder or schizophrenia who are actively engaged in Lucet’s Care Management
programs and who are being treated with antipsychotics will be asked if they have
had a fasting glucose or HbA1c test in the past calendar year. If not, they will be
encouraged to speak with their prescriber to obtain this screening.
Adverse Event Reporting
An editable version of Sentinel Event Reporting Form can be found on the Behavioral
Health Plan Providers page of Lucet website here.
Please follow instructions regarding Adverse Event Reporting below.
Complaint Reporting
Lucet Health defines “Complaints” as an expression of dissatisfaction. There are
several ways you may file a complaint or report dissatisfaction with Lucet Health.
Should you desire to file a complaint regarding any aspect of your experience with Lucet
Health please see the ways you can do this below.
Complaints may be sent by email:
QMComplaints@lucethealth.com (No PHI, please)
Mailed to:
Lucet Health
Complaints
P.O. Box 6729
Leawood, KS 66206
Or sent by fax to:
816-237-2374
Section 5: Managing Utilization
Utilization Management Program
Lucet’s Utilization Management Program is a framework for making benefit and medical
necessity determinations fairly, impartially, and consistently. Lucet bases medical
necessity decisions on the clinical necessity and appropriateness of health care
services, procedures, or settings. Prior to completing medical necessity reviews,
Utilization Managers determine if members are eligible to receive coverage for
requested services based on guidelines set forth in the member’s benefit plan
description.
Lucet uses Medical Necessity guidelines, including LOCUS, CALOCUS, ASAM, and
ESCII, which the Lucet clinical services licensed staff use to determine the medical
necessity of a requested health care service. Further information about these medical
criteria and guidelines can be found in the provider section of the Lucet website.
A physical copy of the Medical Necessity Criteria can be requested by emailing
Network Operations at providerrelations@lucethealth.com, WebPass, or on the
Provider Portal.
Utilization Management
Lucet manages behavioral health benefits requiring utilization management (UM) to
ensure members have access to healthcare services that are timely, appropriate, and
medically necessary. We coordinate care among the member’s primary care physician,
psychiatrist, and behavioral health therapist.
Lucet UM staff are available 24/7/365. Providers can call Lucet or access our website
portal (WebPass) to submit authorization requests. Please refer to the appendix in this
manual for the appropriate plan and phone number to call to address questions about
the UM process, send outbound communication regarding UM inquiries, connect
providers with clinical peers, or initiate reviews with external or independent review
organizations. Lucet staff will identify themselves by name, title, and organization when
initiating or returning calls regarding UM issues. Lucet offers TDD/TYY and language
assistance services for members, providers, and facilities to discuss UM issues.
Conducting Clinical Utilization Management (UM) Review
Utilization managers apply the applicable clinical review criteria to the clinical
information submitted by the facility/provider when making a benefit determination for
the requested treatment and/or level of care. Utilization Managers collect only the
pertinent minimum information necessary to make a
medical necessity determination and ensure the quality of care.
a) Utilization review determinations for pre-service, urgent, and concurrent reviews
are based solely on the clinical information made available to Lucet at the time of
the utilization review determination.
b) Utilization review determinations for post-service reviews are based solely on the
health information submitted by the provider in the medical record at the time the
care was provided.
If Utilization Managers do not have the pertinent minimum clinical information needed to
make a medical necessity determination, the provider may be given an extension of
time to supply additional clinical information. If the provider does not submit the
additional clinical information needed after an extension. The case will be sent
to a physician reviewer to complete a peer review of the information that was provided.
Lucet bases decisions about utilization of services only on eligibility, coverage, and
appropriateness of the health care service. Lucet does not reward nor offer incentives
to employees or personnel who perform utilization review functions to make medically
inappropriate review decisions. Lucet does not reward, hire, promote, or terminate
individuals for issuing denials of coverage.
Members may contact Lucet at the phone number on their insurance card to obtain a
referral to a network provider. Lucet will assist in identifying appropriate providers in
the members’ area and may offer additional assistance with making a timely
appointment with the selected provider.
The plan fact sheets in the appendix include benefit information, eligibility, and any
requirements for pre-notification or authorization for coverage specific to the plan.
Clinical Peers
Clinical reviewers and peers are available whenever a provider has concerns about
access to services, authorization for services, a UM decision, a level of care
recommendation , or other matters relevant to member care. A claim doesn't need to
reach the formal denial or appeal process for such dialogue. External and independent
review organizations are also available.
UM Process Limitations
Please also be aware that the Lucet UM process is designed to comply with the
requirements set forth by federal and state statutes and regulations, accreditation
standards, and plan requirements. In addition, Lucet, as well as providers and facilities,
are required to abide by federal and state confidentiality laws regarding disclosing
a member’s information.
In compliance with confidentiality laws, Lucet will not conduct the UM process in any
manner with third-party billing or management companies unless they provide written
authorization using the applicable plan’s Authorized Representative Form or attest to
obtaining permission from the member via WebPass. This authorization is required
even if the third-party billing or management company has entered a Qualified Service
Organization Agreement with a provider or facility. Lucet will not accept clinical
information from or disclose clinical information to these companies without such
authorization.
Treatment Record Reviews
Providers must cooperate with treatment record reviews, audits, and requests
conducted by Lucet or its designee, a payor, the U.S. Department of Health and Human
Services, the Centers for Medicare and Medicaid Services, a State Department of
Insurance, the Center for Consumer Information and Insurer Oversight, the Comptroller
General and all other governmental and accrediting agencies to which Lucet and
a payor are subject. Lucet may conduct reviews and audits on an unplanned basis as
part of continuous quality improvement and/or monitoring activities. Requirements
pertaining to record reviews and access are summarized below and detailed in your
Agreement with Lucet:
Providers will allow Lucet and payors access to data and information relating to
professional and ancillary care provided to members by the provider to the extent
permitted by and otherwise consistent with applicable laws. As appropriate, providers
will obtain all required approvals and consents to allow providers to disclose such
information to Lucet and payors.
Cooperation and compliance include but are not limited to providing access to any
medical records, governance documents, books, contracts, financial records, protected
health information, and other documents, whether in electronic or paper format, which are
relevant to:
• The services and Covered Services performed under the provider’s
Agreement;
• The determination that services performed are Covered Services;
• Reconciliation and coordination of benefit liabilities;
• Determination of amounts payable;
• Medical audit or review;
• Utilization management, quality improvement, care transitions,
and other clinical program activities;
• Financial transactions associated with the provider’s Agreement;
• Overpayment, underpayment, and documentation reviews; and
• Other relevant matters as required to conduct the audit, evaluation, or
inspection deemed necessary.
Guidelines for Treatment Record Documentation
The following guidelines were developed for treatment records review and to promote
orderliness, security, confidentiality, and adequate documentation. Providers may be
asked to submit several medical records for audit per these guidelines. A passing score
is considered 80 percent or higher.
1. Confidentiality: (a) Treatment records are securely stored, (b) treatment records
are only accessible by authorized personnel, and (c) office staff receives periodic
training in the confidentiality of patient information.
2. Personal/Biographical Information: Personal/biographical information is
documented consistently in the treatment record. Information includes:
• Name or ID number on each page
• Date of birth
• Home address
• Home/work telephone numbers
• Gender
• Employer or school
• Marital or legal status
• Appropriate consent forms/guardianship information
• Emergency contact information
3. Comprehensive Treatment Record Organization: A comprehensive medical
record is defined as a single all-inclusive record of health information that is
comprised of all clinical patient information available to the provider or facility.
The internal information from the provider is integrated with external
information.
a. Practices with satellite offices must have at least one location that
maintains a comprehensive treatment record.
b. Providers must establish a separate record for each member. All contents
of the paper or hard copy treatment record are in an established format
and sequence, either in chronological or reverse chronological order.
c. Each page in the treatment record contains the member's name or unique
identifier. Each treatment record should include information regarding the
member’s address, gender, DOB, employer or school name, relevant
phone numbers, email addresses, emergency contacts, marital status,
legal status, and guardianship, if applicable.
d. An Electronic Medical Record (EMR) may encompass multiple
applications to form a comprehensive record. For example, if
demographic information such as home/work phone number is stored in
one application, and follow-up visit information is stored separately from
the main EMR. All applications must be accessible to the clinical staff
from an individual workstation.
4. Allergies: Documentation of medication allergies is clearly noted. If the patient
has no known allergies, this is noted in the treatment record – typically as NKA
(no known allergies) or NKDA (no known drug allergies). Physician
and nurse practitioner records also clearly describe the reactions associated with
allergies.
5. Special Status Situations: Special status situations include conditions where
the patient is at imminent risk of harm, has suicidal or homicidal ideation with a
plan, or is unable to conduct activities of daily living. Observations of these
situations and prompt referral to the appropriate level of care are documented in
the record. If the situation requires mandated reporting, please document the
report in the medical record.
6. Medication Management: Records contain medication information. This
information includes:
Medication prescribed, including quantity or documentation of no medication
Dosages and usage instructions of each medication (physician and nurse
practitioner records)
Dates of initial prescription or refills (physician and nurse practitioner records)
Herbal medications or over-the-counter medications
7. Informed consent: Records must include evidence of informed consent,
indicating that the patient or family member has been made aware of the
proposed treatment modalities, the risks and benefits of such treatment,
alternative treatments , and the risks of treatment and declining treatment.
8. Alcohol, Tobacco, And Substance Use and/or Abuse:
Documentation includes past and present use of cigarettes, alcohol, and
prescribed, illicit, and over-the-counter drugs, including frequency and quantity.
9. Mental Status Evaluation: The treatment record contains evidence of at least
one mental status evaluation/examination (e.g., patient’s affect, speech, mood,
thought content, judgment, insight, attention or concentration, memory, and
impulse control).
10. History: A psychiatric and medical history was obtained and documented in the
record, outlining the patient’s past treatment and response (or lack thereof). The
history consists of:
• Relevant medical and psychiatric conditions
• Previous treatment dates
• Therapeutic interventions and responses
• Sources of clinical data (e.g., self, mother, spouse, past records)
• Relevant family information
• Consultation reports, if available/applicable (e.g., psychological testing)
• Lab test results, if applicable, in physician and nurse practitioner records
(i.e., Lithium, Depakote, Tegretol levels)
11. Minor Patients Treatment Records: Records of minor patients (under 18 years
of age) contain documentation of prenatal and parental events, complete
developmental histories (physical, psychological, social, intellectual, and
academic), and evidence of family involvement in care within 60 days of the initial
visit. When a minor is prescribed psychotropic medication, documentation
reflects parental consent and that the parent or legal guardian is informed about
the medication, its purpose, side effects, risks, and treatment alternatives.
12. Diagnostic Testing: All diagnostic testing reports and their interpretations are
present (e.g., psychological testing reports, neuropsychological testing reports,
and laboratory reports).
13. Treatment Plan: Within the first three (3) visits, the treatment plan contains (a)
specific, measurable goals, (b) documentation that the treatment plan and/or
goals were discussed with the patient, (c) estimated time frames for goal
attainment or problem resolution, and (d) documentation of the patient’s
strengths and limitations in achieving goals. Each member's personalized
treatment plan should guide the overall treatment process.
14. Diagnosis: The treatment record documents a DSM-V or ICD-10 diagnosis or
clinical impression within the first three visits. “Deferred” or “Rule out” diagnosis
is acceptable but must be revised within three (3) visits. To reflect the member’s
appropriate Risk Adjustment Factor under the Affordable Care Act,
the member’s diagnosis must include all the diagnoses impacting the member,
reflecting the severity of the patient’s overall illness.
15. Treatment Record Notes: Each face-to-face encounter note contains all the
following: (a) reason for the patient’s visit, (b) objective and subjective
documentation of the patient’s presentation, (c) goal of the service, (d) summary
of the intervention/service provided with the member response (e) an updated
treatment plan, and (f) diagnosis being treated during service.
Treatment Record Notes must support the medical necessity of the service
provided and support the billed code. Documentation for each visit must stand
alone and contain all required documentation elements in the encounter note.
For example, a sign-in sheet for group therapy should not be needed in addition
to the encounter note to support member’s group attendance. Likewise, a copy
of an appointment book should not be required in addition to an encounter note
to support time.
i.The treatment record reflects an individualized interaction with the
member. Documentation is not repetitive or reflective of rote or cloned
charting.
ii.Documented abnormalities in the assessment or exam (indicated by check
mark or narrative) also include the provider addressing an intervention or
rationale that reflects the documented abnormality.
16. Group Notes: Group documentation must be for each specific encounter for the
date of service and each session attended, not a collective summary for multiple
sessions or dates of service. Documentation must include:
• Date, start/stop times, and duration of the group
• Purpose of group
• Objective and subjective documentation of the member’s presentation
during group (individualized to the member)
• Summary of the intervention utilized
• Member’s response to the group
• Provider of the group is documented and authenticated with a professional
degree and/or professional credentials
• Documentation must support medical necessity and be connected to
the member’s individualized treatment plan
17. Doctors’ Orders for Drug Screens: Doctors’ orders for drug screens must
include rationale and the substance tested for. Orders for drug screens should
not be standing orders.
18. Legibility: The medical record is legible to someone other than the writer for
paper records and written notes. Documentation contains only those terms and
abbreviations that should be understandable to other medical professionals.
19. Author Identification, Authentication, and Date and Time of Entries: All
entries are dated, including the month, year, start and stop times, and/or duration
the member was seen face-to-face by the rendering provider. Entries must also
clearly identify the rendering provider and be authenticated (signed) by the
individual providing the services with a professional degree (e.g., Ph.D.,
M.D./D.O., LCSW) and/or professional credentials.
Only handwritten signatures and eligible EMR signatures qualify for
authentication. An electronic signature must include a unique personal identifier
such as a code, biometric, or password entered by the author. The signature
must be adhered to the document when created and include the author’s name,
credentials, date of signature, and timestamp. For example, a typed signature
that lacks the above-listed identifiers would not qualify as authentication.
20. Date of Rendered Service: Documentation reflects each service rendered for
the day it was rendered. A summary of services for multiple dates of service or
multiple members is unacceptable.
21. Follow-up Appointments: The medical record documents dates of follow-up
appointments or, as appropriate, a discharge plan. Documentation of follow-up
with the member has occurred if an appointment was missed.
22. Continuity and Coordination of Care: As applicable, the medical record
reflects continuity and coordination of care as evidenced by communication with,
or review of information from, other behavioral health providers, consultants,
ancillary providers, and health care institutions.
23. Coordinating Care with the PCP: Medical records reflect contact with
the member’s primary care physician (PCP), as applicable, and follow-up contact
as needed.
24. Appropriate edits to documentation: Providers should document the services
rendered in the member’s medical record at the time of service. At times,
a provider may determine that the information entered into the medical record is
not entirely accurate. If revisions need to be made to a medical record, amend
and edit the record using the following steps:
a. To remove information from the record, draw a single line through the
words needing removal, ensuring the content is still readable.
b. The individual amending or editing the record must sign and date the
revision.
Documentation should not be created or edited after receipt of a medical record
request for a claim’s payment audit to receive payment.
Request for Psychological/Neuropsychological Testing
Some plans do not require authorization for psychological or neuropsychological
testing. Please review the health plan and the group-specific information in
the appendix at the end of this manual.
For plans requiring psychological or neuropsychological testing authorization, please
use the form on www.lucethealth.com. The form is called “Request for Psychological
Testing.” Complete all fields, including the date of request and testing start date. The
total number of testing hours you plan should be filled in next to the appropriate CPT
code(s) listed on the form.
If you have any questions or want to check the status of your request
for psychological testing, please feel free to contact us. Contact information is found in
the appendix at the back of this manual.
Psychological testing is considered medically necessary when indicated to improve or
enhance psychiatric or psychotherapeutic treatment upon the completion of a clinical
evaluation if required to assist in the differential diagnosis of behavioral or psychiatric
conditions or the development of treatment recommendations.
Psychological testing is not considered medically necessary when done solely for
educational or vocational placement.
Neuropsychological testing is considered to meet the definition of medical necessity
when performed for the evaluation of individuals with cognitive dysfunction due to
injury, disease, or abnormal development of the brain, and is comprised of a set of
formal procedures that utilize reliable and valid tests that specifically focus on
identification of the presence of brain damage, injury, or dysfunction and any
associated functional deficits.
Providers have access to the following resources and tools for Psychological and
Neuropsychological Testing (PNT) Authorizations and Claims:
• A PNT Provider Guide that includes frequently asked questions and CPT Code
information. The PNT Provider Guide is available on the Lucet Health website at:
o Florida: https://lucethealth.com/wp-content/uploads/2023/03/Psych-
Neuropsychology-Testing-Florida-Provider-Guide-1.pdf
o All Other Regions: https://lucethealth.com/wp-
content/uploads/2023/03/Psych-Neuropsychology-Testing-Provider-
Guide-Corporate-1.pdf
• A Provider PNT WebPass Authorization Form Training Guide is posted on the
WebPass website at:
https://webpass.ndbh.com/?__hstc=19738279.02686584ac8fe559af56b12e7037c
147.1674156219106.1674502264503.1674574459636.3&__hssc=19738279.3.16
74574459636&__hsfp=3483462447
• A PNT Testing Criteria Policy is available on the Lucet Health website at:
https://lucethealth.com/wp-content/uploads/2023/01/2023-Lucet-Medical-Policy-
for-Psychological-and-Neuropsychological-Testing.pdf
Non-Medicare Commercial Member and Provider Denial and
Appeal Rights
Philosophy
Lucet takes a population health, member-centric approach that meets members where
they are and matches the level of intervention to the members’ needs. All services are
designed to ensure that members get the proper care at the right time with the right
provider and are connected with needed community supports.
Lucet recognizes that the success of delivering care to members and optimizing clinical
outcomes relies on collaborative relationships with providers. Lucet is dedicated to
working with our provider community to promote the delivery of high-quality care that is
member-specific, clinically necessary treatment in the least restrictive environment.
Non-Medicare Member and Provider Denial and Appeal Definitions
Adverse benefit determination
• A denial, reduction, termination of, or a failure to provide or make payment (in
whole or in part) for a benefit, including any such denial, reduction, termination, or
failure to provide or make a payment that is based on a member's eligibility to
participate in a plan;
• A denial, reduction, or termination of, or a failure to provide or make payment (in
whole or in part) for, a benefit resulting from the application of
any utilization review;
• A failure to cover an item or service for which benefits are otherwise provided
because it is determined to be experimental or investigational or not medically
necessary or appropriate or
• Any cancellation or discontinuance of coverage that has a retroactive effect.
Appeal – A verbal or written request to contest an adverse benefit determination, such
as services that have been denied, reduced, etc.
“Clinical Peer,” “Peer Clinical Reviewer,” or “Physician Reviewer” – A Board
Certified Physician (MD or DO) or other Ph.D. behavioral health care professional who
holds a current, unrestricted license or certificate in a state or territory of the United
States to practice and is in the same or similar specialty as that which typically
manages the health condition, procedures, or treatment under review. If required by the
applicable state, the Clinical Peer is licensed in the state where services were
rendered. Unless expressly allowed by state or federal law or regulation, the Clinical
Peer is in a state or territory of the United States when conducting a peer clinical review
or an appeals consideration. Generally, as a peer in a similar specialty, the individual
must be in the same profession (i.e., the same licensure category as the treating
provider).
“Doc-to-Doc” or “Peer-to-Peer” Conversation - Synonymous terms, defined as a
telephonic clinical discussion about the treatment of a member, conducted between a
Clinical Peer Reviewer and the practitioner who is directing the care of the
member, who is typically the attending physician for the member.
Expedited Appeal – Review of an adverse benefit determination of an urgent care
request involving an admission, continued stay, or other health care service from which
Member has not been discharged, and for which it has been determined that the
member has a medical condition where the time frame for completing a standard appeal
would seriously jeopardize the life or health of the member, or the member's ability to
regain maximum function.
Independent Review Organization (IRO) - An external review company that
conducts independent, external reviews of behavioral health and substance use
services to determine the appropriateness of care based on medical necessity criteria,
level of care requested, and effectiveness of a requested service. IRO-employed
Clinical Peers are board-certified and independently licensed. These reviewers are not
affiliated with Lucet.
Initial Clinical Review – Clinical review conducted by appropriately licensed or
certified health professionals. Initial clinical review staff may approve requests for
admissions, procedures, and services that meet clinical review criteria but may not
make an adverse benefit determination.
Medical Necessity or Medically Necessary- Please refer to the controlling specific
health plan and/or group documents for the definition of Medical Necessity.
Initial Peer Review - A Peer-to-Peer Conversation occurs when care management staff
cannot approve the service request based on the available clinical information.
Post-Service Request (aka Retrospective Request) - A request for coverage of
medical care or services after treatment at the requested level of care has concluded.
Clinical Peer Review Process
Initial Peer Review - When Care Management staff cannot approve the service request
based on the available clinical information, the case is sent to a Clinical Peer for review.
The Clinical Peer offers to conduct a peer-to-peer conversation with the Attending
Physician or Practitioner directing the member’s care in order to obtain or
clarify the information to be used in the benefit determination. Attending providers may
not delegate this responsibility, designate a representative, or use a third-party
billing/management company to participate in the peer-to-peer conversation. If the
discussion occurs and a decision is reached, this part of the process ends. The next
step for the provider and/or member is to request an appeal (see the Appealing Adverse
Benefit Determination section below).
For Inpatient and Residential services, peer-to-peer conversations are available only to
the Attending provider directly involved with the member’s care.
The member’s primary provider/clinician may request and participate in peer-to-peer
conversations for Partial Hospitalization, Intensive Outpatient, and Outpatient services.
Notification of Adverse Benefit Determination- If the Initial Peer Review results in
an Adverse Benefit Determination of the requested service based on lack of medical
necessity, the requesting provider and/or facility and the member are notified of the
adverse benefit determination.
Notification of the adverse benefit determination is given verbally to the
provider and/or facility by Care Management staff at Lucet. Written notification is also
provided to the member, provider, and/or facility. The written notification includes
pertinent information regarding the adverse benefit determination, including:
a. Information identifying the adverse benefit determination
b. Date(s) of the service
c. Name of provider/facility
d. Amount of the claim (if known or applicable)
e. The availability of the diagnosis and treatment codes and their corresponding
meanings upon request
f. Discussion of the pertinent facts about the member's condition and the
contractual or clinical reason and rationale for the adverse benefit
determination and specific reference to the Clinical Review Criteria or benefit
provision used in the decision
g. The qualifications and title of the Clinical Peer and the person making the
adverse benefit determination
h. The benefit provision, guideline, standard, or criteria used in making the
adverse benefit determination, which is available free of charge upon request
i. A statement that the requestor, provider, or facility is entitled to receive, upon
request and free of charge, how to request copies of all documents, records,
and other information relevant to the adverse benefit determination
j. A description of and how to pursue an internal appeal
k. A description of and how to pursue an external appeal
l. Contact information for an office of health insurance consumer assistance or
ombudsman, if available; and
m. The telephone number to be called if there are any questions
Please note: Lucet follows URAC and NCQA standards regarding conducting peer-to-
peer conversations. Prior to the initiation of the appeal process, Lucet offers attending
physicians and treating practitioners the opportunity to have a clinical discussion with
the clinical peer reviewer. Please refer to the respective Health Plan for specific
requirements regarding peer-to-peer conversations.
Appealing Adverse Benefit Determinations
Lucet provides Members/Member representatives, Providers, and Facilities the right to
appeal adverse benefit determinations when medical necessity criteria are unmet.
* Claim denials unrelated to medical necessity criteria (e.g., outside of timely filing,
coding errors, contractual payment issues, etc.) have a different claims dispute
process. Please refer to the Claims Dispute section below for more information about
claims disputes.
*Medical necessity appeal inquiries for Medicare and Federal plans should contact the
respective health plan.
Appeal rights and procedures can vary with each policy. Please refer to the initial denial
letter for specific appeal rights, including but not limited to what, if any, appeal rights are
available, who can request an appeal, where to send appeal requests, and time frames
regarding appeal requests and responses. Lucet’s role in appeals varies by plan and
group. The information in this document is to be used as a general reference guide.
Appeals can be requested telephonically or in writing. Written requests should include
the following information:
• Member’s name, certification/identification number, date of birth
• Date(s) of service and procedure/service that is being appealed
• Treating practitioner’s name and contact information, including phone and fax
number
• Specific reason(s)/rationale for the appeal request; an explanation of why Lucet
should reevaluate the adverse benefit determination; and
• Any relevant clinical information that supports the appeal request, such as
medical records or other supporting documentation
Dispute Type Who Can Request Submission and Timeframes
Expedited Appeal
They are used when there
is disagreement with an
adverse benefit
determination based on
medical necessity criteria.
The expedited appeal
option is available when a
medical necessity-based
adverse benefit
determination could
seriously jeopardize the life
or health of the
Member. The Member
must still receive
treatment
at the requested level of
care, and urgency must be
demonstrated.
Members/ authorized delegates,
providers, facilities
(In
some instances, an Appointment
of Representative (AOR)* form
may be required)
Submission
See Appendix
To Request
180 days from the date of the
denial
(See appendix for policy-
specific rules on timely
filing and submission
information)
LUCET Response
72 hours
Standard Appeal
They are used when
disagreement with an
adverse benefit
determination based on
medical necessity criteria.
The standard appeal option
is available for cases not
meeting the requirements
to expedite the appeals
process.
Members/ authorized delegates,
providers, facilities
(In some instances, an AOR*
form may be required)
Submission
Online:
https://webpass.ndbh.c
om/
Phone:
See appendix
Fax:
816-237-2382
Mail:
LUCET
– Attention Appeals
PO Box 6729
Leawood, KS 66206
-0729
To Request
180 days from the date of the
denial
(see appendix for policy-
specific
rules on timely filing)
LUCET
Response
30 calendar days
Post-Service Request
A request for medical care
coverage or services after
treatment at the requested
level of care has
concluded. This is not a
type of appeal.
Providers, facilities
Submission
Online:
https://webpass.ndbh.c
om/
Phone:
See appendix
Fax:
816-237-2382
Mail:
LUCET
– Attention Appeals
PO Box 6729
Leawood, KS 66206
-0729
To Request
One (
1) year from the date of
discharge (see
appendix for
policy
-specific rules on timely
filing)
LUCET Response
30 calendar days
Claims Dispute
Used to dispute a claim
denied for reasons other
than not meeting medical
necessity criteria. (e.g.,
contractual payment,
coding, and timely filing
issues)
Members/ authorized delegates,
providers, facilities
Contact the respective Health
Plan for Details
*AOR gives a provider/facility permission to request an appeal on a member’s behalf.
Non-Medical Necessity Related Claims Dispute Resolution
Lucet recognizes there may be times when participating providers disagree with how a
claim was adjudicated. If a claim issue cannot be resolved through an initial claim
adjustment request, then a written claim dispute inquiry may be needed. This type of
request is different than an appeal or grievance. Disputes are defined as a written
request from a participating network provider questioning (or disputing) an
adjusted claim that was based upon one of the following reasons:
• Reimbursement concerns (the allowed amount is different than a contracted
fee schedule amount)
• Authorization penalties
• Maximum daily benefit denials
• Timely filing denials
• Claim bundling/unbundling
• Refund/recoupment of monies
Lucet is committed to providing health plan claim dispute guidance. See the
appropriate tables noted below.
Blue Cross Blue Shield Alabama
BCBSAL Dispute Information (Excludes Medicare and FEP plans)
Claim Dispute
A written request from a provider for reconsideration of
a claim payment, reduction of payment
, or denial of
payment for reasons other than not meeting medical
necessity criteria (e.g., timely filing issues, coding,
contractual issues, or clinical editing.)
Claim disputes do
not include appeals on behalf of
subscribers.
This type of appeal is processed in the
appropriate Appeals Department
- refer to the Member
Appeals section of the manual.
How to Submit a Request
Provider Services:
Facilities:
800-760-6852
Participating Providers:
877-231-7239
Online:
https://providers.bcbsal.org
Portal/Web/pa/resources/policies&guidelines/
Provider Appeals
Mail:
Blue Cross and Blue Shield of Alabama Appeals
PO Box
10408
Birmingham, AL 35202
-9562
Fax:
205-220-9562
Arkansas Blue Cross Blue Shield (ABCBS) Commercial HMO
and PPO
ABCBS Dispute Information (Excludes Medicare and FEP plans)
Claim Dispute
A written request from a provider for
reconsideration of a claim payment, reduction
of payment
, or denial of payment for reasons
other than not meeting medical necessity
criteria (e.g., timely filing issues, coding,
contractual issues, or clinical editing.)
Claim disputes do
not include appeals on behalf
of subscribers.
This type of appeal is processed
in the appropriate Appeals Department
- refer
to the Member Appeals section of the manual.
How to Submit a Request
Provider Services:
877-345-5976
Online:
https://www.arkansasbluecross.com/providers
Select View Forms, select Claim Reconsideration
Request Form
Mail:
Arkansas Blue Cross and Blue Shield
Attn:
Medical Re-Review
PO Box 3688
Little Rock, AR 72203
-3688
Arkansas Blue Cross Blue Shield (ABCBS) Federal Employee
Program (FEP) (including State of Arkansas Employees)
All claim dispute inquiries should be directed towards Arkansas Blue Cross Blue
Shield FEP at 800-482-6655.
Arkansas Blue Cross Blue Shield (ABCBS) Medicare
Advantage (MA)
All claim dispute inquiries should be directed towards Arkansas Blue Cross Blue Shield
at 800-827-4814.
Walmart through Arkansas Blue Cross Blue Shield/Blue
Advantage Administrators (BAA)
Walmart Dispute Information
Claim Dispute
A written request
from a provider for
reconsideration of a
claim payment,
reduction of
payment
, or denial
of payment for
reasons other than
not meeting
medical necessity
criteria (e.g., timely
filing issues,
coding, contractual
issues, or clinical
editing.)
Claim disputes
do
not include
appeals on behalf
of
subscribers.
This
type of appeal is
processed in the
appropriate
Appeals
Department
- refer
to the Member
Appeals section of
the manual.
How to Submit a Request
Provider Services: 866
-823-3790
Online:
https://blueadvantagearkansas.com/contact/customer_service.aspx
Select Provider, select Email us (customer service link)
Mail:
Blue Advantage Administrators
PO Box 1460
Little Rock, AR
72203
Florida Blue PPO, including Medicare Advantage
Florida Blue Dispute Information (Excludes Medicare and FEP plans)
Claim Dispute
A written request from a provider for reconsideration of
a claim payment, reduction of payment
, or denial of
payment for reasons other than not meeting medical
necessity criteria (e.g., timely filing issues, coding,
contractual issues, or clinical editing.)
Claim disputes do
not include appeals on behalf of
subscribers.
This type of appeal is processed in the
appropriate Appeals Department
-
refer to the Member
Appeals section of the manual.
How to Submit a Request
Provider Services: 800
-727-2227
Online:
https://floridablue.com/providers/tools
-
resources/provider
-manual
Mail:
Florida Blue
Provider Disputes Department
PO Box 43237
Jacksonville, FL 32203
-3237
Claim inquiry disputes for federal plans should be directed toward Florida Blue. Please see the
Florida Blue HMO, including Medicare Advantage and Blue
Medicare Classic Plus HMO, is available in Hillsborough and
Palm Beach Counties.
Florida Blue Dispute Information (Excludes Medicare and FEP plans)
Claim Dispute
A written request from a provider for reconsideration of
a claim payment, reduction of payment
, or denial of
payment for reasons other than not meeting medical
necessity criteria (e.g., timely filing issues, coding,
contractual issues, or clinical editing.)
Claim disputes do
not include appeals on behalf of
subscribers.
This type of appeal is processed in the
appropriate Appeals Department
-
refer to the Member
Appeals section of the manual.
How to Submit a Request
Provider Services: 800
-727-2227
Online:
https://floridablue.com/providers/tools
-
resources/provider
-manual
Mail:
Florida Blue
Provider Disputes Department
PO Box 43237
Jacksonville, FL 32203-3237
Please see the separate appendix section on Florida Blue Federal Employee Program policies.
Florida Blue Federal Employee Program (FEP)
All claim dispute inquiries should be directed towards Florida Blue at 800-333-2227
(https://fepblue.org).
Florida Blue Medicare Preferred HMO (Florida Blue
and BeHealthy)
All claim dispute inquiries should be directed towards Florida Blue at 800-333-2227.
Blue Cross Blue Shield of Kansas (BCBSKS) PPO
All claim dispute inquiries should be directed towards Blue Cross Blue Shield of Kansas
at (816) 395-3929.
Blue Cross Blue Shield of Kansas (BCBSKS) Solutions/EPO
(Exclusive Provider Organization)
All claim dispute inquiries should be directed towards Blue Cross Blue Shield of Kansas
at (816) 395-3929.
Blue Cross Blue Shield of Kansas (BCBSKS) Federal
Employee Program (FEP)
All claim dispute inquiries should be directed towards Blue Cross Blue Shield of Kansas
at (816) 395-3929.
Blue Cross Blue Shield of Kansas (BCBSKS) Medicare
Advantage
All claim dispute inquiries should be directed towards Blue Cross Blue Shield of Kansas
at (816) 395-3929.
Blue Cross Blue Shield of Kansas City (Blue KC) Blue Care
HMO
Blue KC Dispute Information (Excludes Medicare and FEP plans)
Claim Dispute
A written request from a provider for reconsideration of
a claim payment, reduction of payment
, or denial of
payment for reasons other than not meeting medical
necessity criteria (e.g., timely filing issues, coding,
contractual issues, or clinical editing.)
Claim disputes do
not include appeals on behalf of
subscribers.
This type of appeal is processed in the
appropriate Appeals Department
-
refer to the Member
Appeals section of the manual.
Note: Please refer to the separate appendix sections on Blue KC Medicare
and Federal policies.
How to Submit a Request
Provider Hotline: (816) 395-3929
Provider
claim inquiry: (800) 432-3990
Online:
https://providers.bluekc.com
To efficiently handle
a written request,
please complete a Claim Inquiry form.
An interactive PDF copy of the form is in
the
Forms section on our provider portal
(see
Contact | Resource Directory).
Claim Inquiry disputes for Medicare and Federal plans should be directed toward Bl.
Blue Cross Blue Shield of Kansas City (Blue KC) Medicare
All claim dispute inquiries should be directed towards Blue KC at (816) 395-3929.
Blue Cross Blue Shield of Kansas City (Blue KC) Preferred
Care, Preferred-Care Blue, BlueSelect & BlueSelect Plus
PPO
Blue KC Dispute Information (Excludes Medicare and FEP plans)
Claim Dispute
A written request from a provider for reconsideration of
a claim payment,
reduction of payment, or denial of
payment for reasons other than not meeting medical
necessity criteria (e.g., timely filing issues, coding,
contractual issues, or clinical editing.)
Claim disputes do
not include appeals on behalf of
subscribers.
This type of appeal is processed in the
appropriate Appeals Department
-
refer to the Member
Appeals section of the manual.
How to Submit a Request
Provider Services: (816) 395
-3929,
opt
3
Online:
https://providers.bluekc.com/
To efficiently handle
a written request,
please complete a Claim Inquiry form.
An interactive PDF copy of the form is in
the Forms section on our provider portal
(see Contact | Resource Directory).
Inquiry disputes for Medicare and Federal plans should be directed towards Blue
KC. Please see the separate appendix sections on Blue KC Medicare and Federal
policies.
Blue Cross Blue Shield of Kansas City (Blue KC) Federal
Employee Program (FEP)
All claim dispute inquiries should be directed towards Blue KC at 800-221-2362.
Blue Cross Blue Shield of Louisiana (BCBSLA)
BCBSLA Dispute Information (Excludes Medicare and FEP plans)
Claim Dispute
A written request from a provider for reconsideration of
a claim payment, reduction of payment
, or denial of
payment for reasons other than not meeting medical
necessity criteria (e.g., timely filing issues, coding,
contractual issues, or clinical editing.)
Claim disputes do
not include appeals on behalf of
subscribers.
This type of appeal is processed in the
appropriate Appeals Department
-
refer to the Member
Appeals section of the manual.
How to Submit a Request
Provider
Services: (800) 922-8866
Online:
https://providers.bcbsla.com/
-
/media/Files/Providers/
Provider Dispute Form:
A printable PDF
form is available online
at
www.BCBSLA.com/providers; go to
“Resources” and “Forms
.”
Mail:
BCBSLA
Provider Disputes
P.O. Box 98021
Baton Rouge, LA
70898-9021
(800)991-5638
Claim inquiry disputes for Medicare and Federal plans should be directed toward BCBSLA at
Section 6: Clinical Programs
Philosophy
Lucet care management philosophy is based on a member-driven approach where we
seek to ensure the following:
• A member’s needs are determined at the point of access, ensuring that members
needing behavioral health services have access to the full continuum of care.
• Discharge planning begins at the time of admission to ensure clinically
appropriate aftercare.
• Recovery is the single most important goal for the behavioral health service
delivery system that requires providing member-specific, clinically necessary
treatment in the least restrictive environment available.
• A member’s treatment is always guided by an individualized treatment plan.
• Coordination of care that requires sharing relevant clinical information is done
with appropriate respect for privacy, consistent with all Lucet policies and
applicable laws governing member confidentiality.
• Timely outpatient treatment for behavioral health disorders contributes to
symptom reduction and maintenance of treatment outcomes.
Care Management Program
Lucet Care Management program collaborates with providers and community health
resources to assess, plan, facilitate services, and advocate for members. Such
collaboration promotes optimal health outcomes. Our program incorporates member
education, improves provider awareness, minimizes fragmentation of care within the
healthcare delivery system, and addresses the members' physical and behavioral
health needs.
By serving as a single point of contact, Care Managers use evidence‐based practices
to engage members and partner with providers to assist with treatment adherence and
promote recovery. Care Management is a service with an emphasis on:
• Supporting members’ efforts to take an active role in developing their treatment
plans
• Using a member‐centric holistic approach during transitions of levels of care
• Coordinating referrals to providers, community resources, and caregivers
• Improving member resiliency, self‐management, and self‐care
• Empowering members to adhere to their treatment plan
• Assisting members to achieve time‐limited, individualized, attainable goals
Care Managers are licensed clinicians with expertise in care coordination who
empower members to understand how to self-manage their health condition and
support them in accessing high-quality health care.
As a Lucet provider, you may request Care Management services for a member.
Please see the plan or group-specific contact information in the appendix at the back of
this manual.
Care Transitions Activities
Readmissions often occur when members:
• Lack of preparedness for self‐management roles
• Do not know their discharge plans
• Cannot access providers when problems arise
• Receive minimal input regarding their treatment plans
• Suffer medication errors
• Do not have adequate follow‐up treatment
Lucet Care Transitions activities focus on providing a better member experience,
improving populations' health, and reducing service costs by avoiding readmissions
and improving the quality of service provided to the member.
Adequate Care Transition activities achieve multiple goals:
• Ensures that members and member support systems understand and are actively
engaged in the member’s individualized treatment plan
• Coordinates care with the member’s outpatient behavioral and medical
providers
• Addresses barriers to treatment adherence
• Verifies that follow‐up care is timely and appropriate to the member’s needs.
Lucet Care Transitions activities:
• Help providers and the member understand the importance of post‐hospitalization
aftercare
• Increase the scheduling of and attendance at post‐discharge follow‐up
appointments within seven (7) days
• Increase member understanding, participation, and adherence to their treatment
plan
• Assist members in identifying and resolving any barriers that may exist to
attending aftercare appointments
Member Self-Management and Preventive Health Tools
Lucet offers self-management tools derived from scientific evidence that
provide members with information in the areas of emotional well-being, relationships,
and health, including:
• Smoking and tobacco use cessation
• Diet, fitness, and nutrition
• Healthy eating
• Managing stress
• Addiction
• Emotional health assessments
• Recovery and resiliency
• Treatment monitoring
These materials are available through the www.lucethealth.com website and have
been evaluated for language that is easy to understand, taking members' unique needs
into account. Self-management tools are reviewed every two years and are updated
more frequently if new evidence is available.
Condition-specific preventive health and educational tools are also available
to providers and members through www.lucethealth.com. Evidence-based information
is available in the areas of depression, bipolar disorder, ADHD, Autism, and other
common behavioral health conditions to help members navigate through diagnosis,
treatment, questions, and concerns. If you want more information, please see the plan
or group-specific contact information in the appendix at the back of this manual.
Specialty Programs
Child & Adolescent
• A dedicated team of CMs that specialize in helping youth and their families
•
Strong knowledge of resources and treatment options specific to this population
•
Works to avoid unnecessary admissions by connecting families with appropriate
treatment and resources
•
Specialized rounds with a board-certified child psychiatrist
•
Monthly didactic meeting to continue CM's knowledge growth on a variety of
topics and diagnoses
Eating Disorder
• Shift individual expertise to a dedicated team with specific knowledge of
community specialists and resources
•
Specialty team is comprised of UM, CM, and Psychiatry to increase support
when navigating and identifying gaps in care
•
Increased Collaboration with medical providers and health plan partners
•
Specialized rounds with Lucet medical directors and eating disorder experts
SUD Hybrid
•
High-risk SUD population assigned to a specific SUD specialist who serves as a
single point of contact
•
SUD specialist coordinates between providers, members, families, and outpatient
providers
•
Weekly rounds with internal Lucet Addictionologist
•
SUD specialist leverages both UM and CM activities to provide a consistent and
positive member and provider experience
•
Specialized connection to local community SUD providers and resources
Autism Resource Program
Lucet’s Autism Resource Program collaborates with providers and members to support
and advocate for members with autism. Such collaboration promotes optimal health
and quality of life outcomes. Our program supports coordination of care, encourages
adherence to clinical best practice guidelines, and offers a wide variety of referrals and
education to promote optimal treatment outcomes.
Essential Components of ABA Treatment
• Training technicians to perform the following services:
o Carry out treatment protocols accurately, frequently, and consistently;
o Record data on treatment targets;
o Record notes;
o Summarize and graph data;
• Ongoing direction of technician.
• Ongoing, frequent review and analysis of direct observational data on treatment
targets.
• Modification of treatment targets and protocols based on data.
• Training technicians, family members, and other caregivers to implement revised
protocols.
• A complete medical record that consists of the following:
o All assessments performed by the Behavior Analyst, using direct
observation.
o Preferred skills assessments must be developmentally and age-
appropriate and include non-standardized curriculum assessments such
as the ABLLS, VB-MAPP, or other developmental measurements
employed during pre-treatment assessments. Only those portions of
assessments that address core deficits of autism are medically necessary;
this excludes assessments or portions of assessments that cover
academic, speech, vocational skills, etc.
o Individualized treatment plan with clinically significant and measurable
goals that clearly address the member’s active core deficits of ASD. Goals
should include the date of treatment introduction, measured
baseline/present level of performance of the targeted goal, the objective
present level of behavior, mastery criteria, estimated date of mastery, and
a specific plan for generalization of skills.
o Functional Behavior Assessment to address targeted problematic
behaviors with operational definition and provide data to measure
progress, as clinically indicated.
o Documentation of treatment participants, procedures, and setting.
Requested hours should reflect the provider’s ability to provide treatment
as well as the member’s availability to participate.
o Plan to coordinate care with member’s other qualified healthcare
professionals to communicate pertinent medical and/or behavioral health
information.
• Transition and aftercare planning that includes the following:
o Begin during the early phases of treatment
o Focus on the skills and supports required for the member to transition
toward their natural environment, as appropriate to their realistic
developmental abilities.
o Include systematic titration of treatment hours based on progress.
o Identify appropriate services and supports for the period following ABA
treatment.
o Include a planning process and documentation with active involvement
and collaboration with a multidisciplinary team to include caregivers.
o Long-term outcomes must be developed specifically for the individual with
ASD, be functional in nature, realistically attainable for the member’s level
of functioning, and focus on skills needed in current and future
environments.
o Realistic expectations should be set with current treatment plan goals
connecting to long-term outcomes.
o Transition and aftercare planning may change over time based on
member progress, targeted behavior levels, and realistic outcomes of
treatment.
• Training family members and other caregivers to implement selected aspects of
the treatment plan. Caregiver participation is crucial to ABA treatment and should
begin at the onset of services. Caregivers and providers should mutually agree
upon the provider’s clinical recommendations for the amount and type of
caregiver training sessions.
o Caregiver training is defined as the education and development of
caregiver-mediated ABA strategies, protocols, or techniques directed at
facilitating, improving, or generalizing social interaction, activities of daily
living, skill acquisition, and behavior management, to include
observational measures for assurance of treatment integrity. Caregiver
training is necessary to address the member’s appropriate generalization
of skills, including daily living activities, and potentially decrease familial
stressors by increasing the member’s independence.
o Caregiver training goals submitted for each authorization period must be
specific to the member’s identified needs. They should include goal
mastery criteria, data collection, behavior management procedures, if
applicable, and procedures to address ABA principles such as
reinforcement, prompting, fading, and shaping. Each caregiver goal
should include the date of introduction, current performance level, and a
specific plan for generalization. Goals should include measurable criteria
for the acquisition of specific caregiving skills.
o It is recommended that one (1) hour of caregiver training occurs for the
first ten (10) hours of direct line therapy, with an additional 0.5 hours for
every additional ten (10) hours of scheduled direct line therapy unless
contraindicated or caregiver declines. Caregiver training hours should
increase to a higher ratio of total direct line therapy hours if member goals
address activities of daily living, as the provider plans for transition to a
lower level of care within the next six (6) months or, as the member comes
within one (1) year of termination of benefits based on benefit coverage.
o If parents decline or are unable to participate in caregiver training, a
generalization plan should be created to address members’ skill
generalization across environments and people.
o Caregiver training does not include training of teachers, other school staff,
other health professionals, counselors, or trainers in ABA techniques.
However, caregiver training can include teaching caregivers how to train
other professionals or people involved in the member’s life.
DIAGNOSTIC INSTRUMENTS AND SCREENING ASSESSMENTS:
Screening Measures: These are brief assessments designed to identify children
needing a comprehensive evaluation secondary to risks associated with delay, disorder,
or disease that interfere with normal development. Screening measures differ from
diagnostic measures in that they typically require less time and training to administer
and have high rates of false positives. Screening measures' results indicate the risk
level for disability as opposed to the provision of a diagnosis. Screening measures are
not appropriate standalone support for an autism diagnosis and should be followed by
in-depth assessments. Additional acceptable documentation includes autism-specific
standardized assessments or a detailed clinical note based on a comprehensive review
of DSM-5 signs and symptoms. Examples of screening measures include:
• Autism Spectrum Rating Scale (ASRS), short form
• Childhood Autism Rating Scale, second edition. (CARS-2)
• Childhood Autism Spectrum Test. (CAST)
• Social Communications Questionnaire (SCQ)
• Autism Behavior Checklist (ABC)
• Gillian Autism Rating Scale (GARS)
• Checklist for Autism in Toddlers (CHAT)
• MCHAT R F with follow-up questions (score 3-7)
• MCHAT R without follow-up questions (score 8-20)
Diagnostic assessments: These offer significant detail concerning specific deficits
and/or survey a broader swath of core behaviors in autism. The reliability and validity of
the instrument are defined in depth. Reliability gauges the extent to which the
instrument is free from measurement errors across time, across raters, and within the
test. Validity is the degree to which other evidence supports inferences drawn from the
scores yielded by the instrument. This is often grouped into content, construct, and
criteria-related evidence. These assessments also provide a measure of the severity of
illness.
Standardized Autism Diagnostic Assessments
• Autism Diagnostic Observation Schedule, second edition (ADOS-2)
• Autism Diagnostic Interview, revised (ADI-R)
• Social Responsiveness Scale, second edition (SRS-2)
• DSM-5 Checklist
Standardized Adaptive Assessment Instruments
Adaptive assessments are a type of psychological testing that is vetted, standardized,
and norm-referenced. These assessments provide a pathway to allow comparison of an
individual member’s score to a norm-referenced mean.
• Vineland Adaptive Behavior Scale (VABS)
• Adaptive Behavior Assessment Scale (ABAS)
• Behavior Assessment System for Children (BASC)
• Pervasive Developmental Disorder Behavior Inventory (PDDBI)
Standardized Cognitive Assessments
• Ages & Stages Questionnaires (ASQ)
• Battelle Developmental Inventory, second edition (BDI-2)
• Developmental Assessment of Young Children 2 (DAYC-2)
• Developmental Profile-3 (DP-3 or DP-4)
• Differential Abilities Scale (DAS)
• Kaufman Brief Intelligence Test – Second Edition (KBIT-2)
• Reynolds Intellectual Assessment Scale
• Leiter International Performance Scale-R
• Mullen Scales of Early Learning
• Bayley Scales of Infant Development
• Kaufmann Assessment Battery for Children, second edition (K-ABC-II)
• Wechsler Preschool and Primary Scale of Intelligence, third edition (WPPSI-III)
• Wechsler Intelligence Scale for Children, fourth edition (WISC-IV)
• Test of Non-Verbal Intelligence, fourth edition (TONI-4)
Non-Standardized Curricular Assessments
These tools are developed to provide a curriculum-based individual assessment. They
are criterion-referenced, as opposed to psychological testing, which is vetted,
standardized, and norm-referenced. The latter offers a pathway to allow comparison of
an individual member’s score to a norm-referenced mean. Examples include:
• Assessment of Basic Language and Learning Skills (ABLLS)
• Verbal Behavior Milestones Assessment and Placement Program (VBMAPP)
• PEAK
• Essentials For Living (EFL)
• Assessment of Functional Living Skills (AFLS)
Out of State claims coding:
ABA service providers who are in-network with their local Blue Cross and Blue Shield
plan and contracted to utilize ABA service codes that are different from the approved list
will be eligible for reimbursement for service codes equivalent to the covered
ABA service codes listed here: Billing Codes | ABA Coding Coalition. Service codes not
equal to the approved service codes do not qualify for reimbursement. Out-of-state ABA
service providers should discuss approved service codes during the clinical review of
requested services. For additional information about code usage, please review the
ABA Coding Coalition Supplemental Guidance on Interpreting and Applying the 2019
CPT Codes for Adaptive Behavior Services.
*CPT Definition of Time Spent with Patient that is Eligible for Reimbursement:
Face to Face time for outpatient visits is reimbursable and includes:
1. Time spent with patient
2. Time spent with family
3. Time spent with patient and family
The non-face-to-face time (activities that may occur before, during, or after a visit) is
included in the work for each CPT code reimbursement. These non-face-to-face
activities are, therefore, not eligible for claim submission, independent of face-to-face
time. These non-reimbursable events include such activities as a review of records,
arranging further services, communicating with the professionals, the patient, or the
family through written reports and telephone contact, and other non-face-to-face
activities. (REF pg. 8 of CPT Handbook 2016)
Additional information:
• All request forms are located on WebPass. For WebPass access, please
contact your Autism Resource Care Manager, 1-877-563-9347, or
prwebpass@lucethealth.com.
• Please submit your request at least two weeks prior to authorization
expiration to ensure ample time to review the request. Reviews of
authorization requests may take up to 15 days.
• Prior to submitting a request, please verify that ABA is a covered benefit
for the member’s current diagnosis and if it requires prior authorization.
• Changes to current authorizations can be completed using the ABA
Amended Request form including provider changes, increase/decrease in
hours, change of service location, additional code requests, or additional
goals for review.
• Ensure all demographic information (service location address, last name,
NPI, etc) is updated and accurate to prevent claims issues. This may be
done through your provider portal, by contacting the health plan, or
through contacting your provider representative depending on your state.
•
Section 8: Provider Resources
Lucet is committed to partnering with our providers and facilities in their treatment of
members with substance use and mental health disorders. This partnership ensures
members have access to timely, appropriate treatment. One of our roles in this
partnership is to provide up-to-date, evidence-based best practice provider resource
tools and models. Best practice models are no substitute for sound clinical judgment but
are intended to enhance compliance with current best practice treatments, focusing on
positive member outcomes.
Click on the links in each section to access Lucet Clinical Best Practice Resources.
Telehealth Standards
Provider Telehealth Care Standards - To access the Provider Telehealth Care
Standards document, please visit the provider section of our website -> click “Provider
Resources”-> select the applicable Health Plan-> view “Telehealth Best Practices”
Primary Care Providers
Primary Care Provider Toolkit-A primary care provider (PCP) is faced with helping
patients with their mental health. In fact, primary care providers provide most mental
health treatment in primary care settings. At times, patients will say that they have a
behavioral health concern or diagnosis, but often, it is difficult to tell. We believe that
mental health is essential, not just because it affects a person’s overall well-being but
also because when it goes undetected and untreated, it often gets worse. Untreated or
inappropriately treated mental health concerns negatively impact a person’s quality of
life, can interfere with proper management of co-occurring medical treatment, and can
lead to increased utilization of the healthcare system, including frequent and often
lengthy primary care visits. That’s why we’ve created a PCP toolkit.
HEDIS
HEDIS Toolkit-This is the Lucet Healthcare Effectiveness Data and Information Set
(HEDIS
®
) Provider Toolkit. HEDIS was developed by the National Committee for Quality
Assurance (NCQA
®
). HEDIS is a set of performance measures used in the healthcare
industry, is part of NCQA accreditation, and is an essential activity for Lucet to ensure
members receive the highest quality care from providers.
This toolkit aims to offer a better understanding of the current HEDIS behavioral health
performance measures and to provide guidance to healthcare providers on how they
can help improve the quality of care and performance of the HEDIS measures.
Emergency Department
Emergency Department Toolkit-Lucet is committed to working with participating
providers to improve the quality of care for members. Providers are at the heart of
healthcare delivery, serving members when they are most vulnerable. A better quality of
life for our members starts with you. Our goal is to help you help them.
The purpose of this toolkit is to offer guidance and a better understanding of the HEDIS
behavioral health performance measures related to follow-up care for members after
being seen in the emergency department for mental illness, substance use, or drug
overdose.
Member Facing
Member Facing Resources-The Lucet Resource Center contains vital information to
help members start their journey to better mental health. Providers can access, print,
and post or hand out posters and pamphlets for member education. Topics include:
Self-help tools
Screening tools
PTSD toolkit
Suicide Awareness
Stamp out Stigma
Autism Resource Center
Substance Use Disorder Case Management
Members can also obtain information about Lucet programs provider services and print
necessary forms such as consent to release information and health record requests.
Section 9: Fraud, Waste and Abuse
Lucet is committed to preventing, identifying, investigating, and reporting fraud, waste,
and abuse. The Compliance Department educates what activities constitute fraud,
waste, and abuse. Lucet regularly monitors and audits claims and reports all fraud
and/or abuse cases to the appropriate health plan or governmental agency. Lucet
expects its Providers and Facilities to comply with all applicable state and federal laws
pertaining to fraud and abuse.
Definitions
Fraud is knowingly and willfully executing, or attempting to execute, a scheme or
artifice to defraud any health care benefit program or to obtain (by means of false or
fraudulent pretenses, representations, or promises) any of the money or property
owned by, or under the custody or control of, any health care benefit program.
Waste is the overutilization of services or other practices that, directly or indirectly,
result in unnecessary costs to health care programs. Waste is generally not considered
to be caused by criminally negligent actions but rather by the misuse of resources.
Abuse includes actions that may, directly or indirectly, result in unnecessary costs to
health care programs, improper payment, payment for services that fail to meet
professionally recognized standards of care or medically unnecessary services. Abuse
involves payment for items or services when there is no legal entitlement to that
payment, and the provider has not knowingly and/or intentionally misrepresented facts
to obtain payment. Abuse cannot be differentiated categorically from fraud because the
distinction between “fraud” and “abuse” depends on specific facts and circumstances,
intent and prior knowledge, and available evidence, among other factors.
Examples of fraud, waste, and abuse include:
• Billing for services that have not been provided, including falsifying records to
show delivery of such services
• Submitting false information about services performed or billing for services at a
level of complexity higher than services provided or documented in the medical
records
• Making a false statement or misrepresenting a material fact in any application for
any benefit or payment
• Presenting a claim for services when the individual who furnished the service was
not appropriately licensed
• Failing to return an overpayment within sixty (60) days after the later of either the
date on which the overpayment was identified or the date any corresponding cost
report was due
• Providing or ordering medically unnecessary services or tests
• Paying for referrals of Federal health care program beneficiaries
• Billing a health plan for appointments that patients did not attend
• Charging in excess of services or supplies
Audits
Lucet performs random post-payment audits of provider and facility claims and medical
records to identify fraudulent billing practices. Other entities may also conduct audits,
such as payors, the U.S. Department of Health and Human Services, the Centers for
Medicare and Medicaid Services, State Departments of Insurance, the Center for
Consumer Information and Insurer Oversight, and other governmental and accrediting
agencies to which Lucet and payors are subject. No specific intent to defraud is
required to find that a violation of law occurred.
Lucet expects its providers and facilities will fully cooperate and participate in all audit
requests. This includes, but is not limited to, allowing Lucet access to member medical
records and progress notes and permitting Lucet to conduct on-site audits or desk
reviews.
Upon claims analysis and a review of member medical records, Lucet will provide a
detailed letter to the provider or facility outlining any deficiencies pertaining to poor
documentation or a lack of evidence to support paid services. Providers and facilities
should provide a corrective action plan to remedy such deficiencies that includes but is
not limited to the identified issue, corrective action to be taken, responsible parties, and
the effective dates.
Claim Recoupment and Appeals
Upon the results of a claim audit analysis and/or Claims Integrity medical record
review, Lucet reserves the right to recommend recoupment of any claims that may
have been paid incorrectly or paid pursuant to billing practices that did not adhere to
Lucet’s or the applicable plan’s billing policies and procedures.
Post-payment audit appeals:
A. First-Level appeal: Services denied as a part of the post-pay audit process may
be appealed in writing within forty-five (45) days of receipt of the findings or
within the timeframe outlined in the findings letter. Written notification of appeal,
specific claim lines being appealed, and any additional supporting documentation
should be provided with the appeal. A member will make the first level appeal
determination of Lucet’s Claims Integrity Management team. Documentation with
edits or corrections will not be accepted as part of the appeal. Appeals are to be
submitted as instructed in the findings letter.
Second-Level Appeal: A provider may request a second and final appeal in writing
within 45 days of receipt of the first-level appeal determination or within the timeframe
outlined in the appeal determination letter. Written notification of appeal, specific claim
lines being appealed, and any additional supporting documentation should be provided
with the appeal. The second and final appeal determination will be made by a Lucet
Medical Director or Independent Review Organization (IRO) within 45 days of receipt of
the appeal. Documentation with edits or corrections will not be accepted as part of the
appeal. Second-level appeals are to be submitted as instructed in the letter containing
the determination from the first-level appeal.
Excluded Persons
Providers and facilities participating in federally funded health care programs must
determine whether their employees and contractors are excluded from participating. It is
considered fraud for a provider or facility that has been excluded from a
federally funded health care program to submit a claim for services. The Department of
Health and Human Services (HHS), through the Office of Inspector General (OIG),
maintains the List of Excluded Individuals/Entities (LEIE). This list may be accessed
online here. Providers and facilities participating in federally funded health care
programs must search this website at least monthly to identify workforce members who
are excluded from receiving payment or providing services for federally funded health
care programs. Excluded individuals must be promptly removed from work involving
Federal and State health care programs.
Section 10: Billing Assistance
Billing and Missed Appointments
Lucet does not authorize payment to providers for missed appointments, nor may
a member be billed unless they have agreed, in writing and prior to beginning treatment
with the provider, to pay out of pocket for any missed appointments.
Psychiatric Diagnostic Evaluations
For psychiatric diagnostic evaluation with medical services, routine performance of
additional psychiatric diagnostic evaluation of patients with chronic conditions is not
considered medically necessary. A psychiatric diagnostic evaluation can be conducted
once, at the onset of an illness or suspected illness. The same provider may repeat it
for the same patient if an extended hiatus in treatment occurs, if the patient requires
admission to an inpatient status for a psychiatric illness, or if a significant change in
mental status requires further assessment. An extended hiatus is generally defined as
approximately six (6) months from the last time the patient was seen or treated for their
psychiatric condition. A psychiatric diagnostic evaluation may also be utilized again if
the patient has a previously established neurological disorder or dementia and there
has been an acute and/or marked mental status change, or a second opinion or
diagnostic clarification is necessary to rule out additional psychiatric or neurological
processes, which may be treatable.
Medication-Assisted Treatment (MAT) Services
MAT services are only reimbursable in an outpatient setting. Facilities may not be
reimbursed when the MAT services are conducted in a facility setting, such as Acute
Inpatient, Residential, Partial Hospitalization, or Intensive Outpatient Services.
Maximum Visits per Day
Benefits will be authorized for only one (1) professional unit per day unless a plan
specifies otherwise, except for the following combined services:
• Outpatient psychotherapy or group therapy with a non-psychiatrist provider plus
medication management with a psychiatrist on the same day
• Outpatient psychotherapy or evaluation plus psychological testing on the same
day. Please review the Center for Medicare and Medicaid Services (CMS)
Medical Unlikely Edit (MUE) for specific procedure code limits.
Concurrent and Overlapping Services
Providers should not bill concurrent services, including two or more direct services
being delivered at the same time to the same member. Additionally, providers
should not deliver overlapping services, meaning delivering non-group services to more
than one Member at the same time.
Billing Submission
Ensure documentation supports the number of units and/or time-based coding billed.
• Services may only be billed in whole units. Partial units will not be accepted. For
time-based codes, please refer to the CPT time rule below.
• Only the provider rendering the face-to-face session with a member can bill for
that service. Unless present for the entire session, providers may not bill for
services rendered by interns and provisionally licensed providers.
• Submissions for Inpatient residential services will be paid for the entire stay
using the rate that is in effect on the date of admission.
• Applied Behavior Analysis (ABA) services documentation guidelines are
provided within this section.
CPT Time Rule
Please refer to the most recent version of the CPT Manual for the latest information
regarding billing codes. According to the CPT Manual, time is defined as the face-to-
face time spent with the member. A unit of time is attained when the midpoint is
passed. For example, an hour is attained when 31 minutes have elapsed (more than
midway between zero and sixty). A second hour is attained when 91 minutes have
elapsed. When codes are ranked in sequential typical times and the actual time is
between two typical times, the code with the typical time closest to the actual time is
used.
Coding Outpatient Psychotherapy Sessions Provided Without E/M Services
Actual length of session
Code As
Code Description
0-15 minutes
Not reported
-
16-37 minutes
90832
30 minutes
38-52 minutes
90834
45 minutes
53-89 minutes
90837
60 minutes
2017 CPT Manual, Page xv-xvi
Common Billable CPT and Revenue Codes
Below is a list of commonly billed codes. Please refer to the most recent version of the
CPT Manual and your fee schedule regarding qualified providers for each service.
Service
Code
Treatment Description
Psychotherapy Service Codes
+90785
Interactive complexity
90791
Psychiatric diagnostic evaluation (no medical services)
90792
Psychiatric diagnostic evaluation (with medical services)
90832
Psychotherapy, 30 minutes with
a patient
+90833
Psychotherapy, 30 minutes with
a patient with E/M Service
90834
Psychotherapy, 45 minutes with patient
+90836
Psychotherapy, 45 minutes with the patient when performed
with E/M Service
90837
Psychotherapy, 60 minutes with
patient
+90838
Psychotherapy, 60 minutes with the patient when performed
with E/M Service
90839
Psychotherapy for crisis, first 60 minutes
+90840
Psychotherapy for crisis, each additional 30 minutes
90845
Psychoanalysis
90846
Family Psychotherapy without Patient Present, 50 minutes
90847
Family Psychotherapy with Patient Present, 50 minutes
90853
Group Psychotherapy
Psychotherapy and Psych Testing Codes
Service Code
Treatment Description
96130
Psychological Testing Evaluation services by a physician or
qualifying health care professional, including integration of
patient data, interpretation of standardized test results and
clinical data, clinical decision
making, treatment planning, and
report and interactive feedback to the patient, family member
(s), or caregiver (s), when performed, the first hour
+96131
Each additional hour (List separately in addition to code for
primary procedure)
96132
Neuropsychological testing evaluation services by a physician
or other qualified health care professional, including integration
of patient data, interpretation of
standardized test results and
clinical data, clinical decision making, treatment planning
, and
report and interactive feedback to the patient, family member
(s) or caregiver (s), when performed, first hour
+96133
Each additional hour (List separately in addition to code for
primary procedure)
Test Administration and Scoring
96136
Psychological or neuropsychological test administration
and scoring by
a physician or other qualified health care
professional, two or more tests, any method, first 30
minutes
+96137
Each additional 30 minutes (List separately in
addition to
code for primary procedure)
96138
Psychological or neuropsychological test administration
and scoring by technician, two or more tests, any
method; first 30 minutes
+96139
Each additional 30 minutes (List separately in
addition to
code for primary procedure)
Automated Testing and Result
96146
Psychological or neuropsychological test administration,
with
a single automated instrument via an electronic
platform, with automated result only
Neurobehavioral Status Exam
96116
Neurobehavioral status exam (clinical assessment of
thinking,
reasoning, and judgement, e.g., acquired
knowledge, attention, language, memory,
planning, and
problem solving, and visual spatial abilities), by physician
or other qualified health care professional, both face
-to-
face time with the patient and time interpreting test
results and preparing the report; first hour
+96121
Each additional hour (List separately in addition to code
for primary procedure)
“+” Indicates an Add-On Code to be reported with another code
APA 2019 Psychological and Neuropsychological Testing CPT Codes & Descriptions
may be accessed https://www.apaservices.org/practice/reimbursement/health-
codes/testing/codes-descriptions.pdf here
E/M
99202
Office or other outpatient visit for E/M with new patient which requires
a medically appropriate history and/or examination and straightforward medical
decision making. When using total time on the date of the encounter for code selection,
15 minutes must be met or exceeded.
99203
Office or other outpatient visit for E/M with new patient which requires
a medically appropriate history and/or examination and low level of medical decision
making. When using total time on the date of the encounter for code selection, 30
minutes must be met or exceeded.
99204
Office or other outpatient visit for E/M with new patient which requires
a medically appropriate history and/or examination and moderate level of medical
decision making. When using total time on the date of the encounter for code selection,
45 minutes must be met or exceeded.
99205
Office or other outpatient visit for E/M with new patient
which
requires a medically appropriate history and/or examination and high level of medical
decision making. When using total time on the date of the encounter for code selection,
60 minutes must be met or exceeded.
99211
Office or other outpatient visit for E/M with established patient
(minimal)
99212
Office or other outpatient visit for E/M with established patient
which requires a medically appropriate history and/or examination and straightforward
medical decision making. When using total time on the date of the encounter for code
selection, 10 minutes must be met or exceeded.
99213
Office or other outpatient visit for E/M with established patient
which requires a medically appropriate history and/or examination and low level of
medical decision making. When using total time on the date of the encounter for code
selection, 20 minutes must be met or exceeded.
99214
Office or other outpatient visit for E/M with established patient
which requires a medically appropriate history and/or examination and moderate level
of medical decision making. When using total time on the date of the encounter for
code selection, 30 minutes must be met or exceeded.
99215
Office or other outpatient visit for E/M with established patient
which requires a medically appropriate history and/or examination and high level of
medical decision
making. When using total time on the date of the encounter for code
selection, 40 minutes must be met or exceeded.
99221
Initial inpatient/residential evaluation – detailed or
comprehensive, low complexity
99222
Initial inpatient/residential evaluation – comprehensive, moderate
complexity
99223
Initial inpatient/residential evaluation – comprehensive, high
complexity
99231
Subsequent inpatient/residential visit – problem focused, straight
forward or low complexity
99232
Subsequent inpatient/residential visit – problem focused,
moderate complexity
99233
Subsequent inpatient/residential visit – detailed, high complexity
99238
Hospital discharge day management, 30 minutes or less
99251
Initial inpatient consultation (problem focused, straight forward)
99252
Initial inpatient consultation (expanded problem focus, straight
forward)
99253
Initial inpatient consultation (detailed, low complexity)
99254
Initial inpatient consultation (comprehensive, moderate
complexity)
99255
Initial inpatient consultation (comprehensive, high complexity)
CPT and REVENUE CODES IN NUMERICAL ORDER
124
Inpatient Day
– Mental Health
126
Inpatient Day
– Substance Use
129
Sub
-Acute/ Residential Rehabilitation
762
Observation Bed
901
Electroconvulsive Therapy
-Facility Code
905
Intensive
Outpatient (IOP) – Psychiatric
906
Intensive Outpatient (IOP)
– Chemical Dependency
912
Partial Care (PHP)
- Less Intensive
913
Partial Care (PHP)
- Intensive
1001
Residential
- Psychiatric
1002
Residential
-Chemical Dependency
If the time worked is more than half the time permitted by the code, then that code can be used.
For example, to bill under Code 90832, you must work a minimum of 16 minutes. If you worked
16 - 37 minutes, you would use the 30-minute code (90832); for 38 - 52 minutes, you would use
the 45-minute code (90834); and for 53+ minutes, you would use the 60-minute code (90837).
Reimbursement for services is subject to Plan guidelines.
Section 11: Compliance Program Overview
Lucet’s Compliance Program outlines Lucet’s commitment to conducting business in
accordance with state and federal legal requirements and ethical standards. Lucet
encourages providers and facilities to create a compliance program to prevent, detect,
and correct potential noncompliance and to combat fraudulent conduct. To aid in
developing compliance programs and using internal controls to monitor adherence to
applicable laws and health plan requirements, The U.S. Department of Health and
Human Services Office of the Inspector General has developed Compliance Program
guidance for individual and small group health care practices and hospitals.
Reporting Noncompliance
Lucet maintains a Compliance HelpLine for anonymous reporting of
suspected noncompliance, fraud, abuse, and concerns about unethical conduct. To
report a compliance concern, please contact Lucet’s Compliance Department.
Phone 855-580-4871
Email compliance@lucethealth.com
Online Compliance and Ethics Concern Form
Mail Lucet Compliance Department
PO Box 6729
Leawood, KS 66206
Lucet will not retaliate against any person who, in good faith, reports
suspected noncompliance, fraud, or abuse to Lucet, a health plan, federal or state
governments, or any regulatory agency.
HIPAA Privacy and Security
To help inform members about the use and disclosure of their medical information,
please refer to the Notice of Privacy Practices found at www.lucethealth.com. Member
rights as they pertain to health information and how Lucet uses and discloses protected
health information.
Lucet has implemented privacy and security measures to prevent the unauthorized
release of or access to personal information, including using encrypted email. As HIPAA
Covered Entities, providers and facilities must also safeguard protected health
information sent via email. The confidentiality of any communication transmitted to
or from Lucet via unsecured/unencrypted email cannot be guaranteed. Please do
not send medical or personal information via non-secure email.
Privacy Policy
Please refer to the Privacy Statement found at www.lucethealth.com. This statement
explains how personal information is collected and used by Lucet and how this
information may be disclosed to third parties.
When a visitor performs a search on www.lucethealth.com, Lucet may record
information identifying the visitor and/or linking the visitor to the search performed.
Lucet may also record limited information for every search request and use that
information to solve technical problems with the service and to calculate overall usage
statistics.
Section 12: Appendix
Appendix for Blue Cross and Blue Shield Plans
(Fully insured, Federal Employee Program and Self-Funded
accounts)
Note: Information in the appendix is specific to each plan (i.e., not a Lucet process).
For terms and definitions, refer to the member’s plan or call the Customer Service
number on their ID card. Information may be subject to change. If you have questions,
please direct them to the applicable plan.
Blue Cross Blue Shield of Alabama
(including Southern Company)
Provider Network through Lucet
Outpatient Authorizations
(Lucet)
Prior authorization is required for ABA therapy. All
other outpatient services may be reviewed
retrospectively. Please utilize WebPass
Precertification
(Lucet)
Please call 800-248-2342
Benefits and Eligibility
(Lucet)
Please call 855-339-8558
or utilize WebPass
Provider Relations
(Lucet)
Please call 888-611-6285, submit a support case to
Login (lucethealth.com), or email
Providersupport@Lucethealth.com.
Medical Necessity Appeals
(Lucet)
Expedited Appeals 800-248-2342
Standard Appeals WebPass
Claims Inquiries
(BCBSAL)
Please call 205-220-6899 or Ask-EDI@bcbsal.org
See below for additional details.
Deaf or Hard of Hearing
(Alabama Relay)
800-548-2546 (Voice)
800-548-2546 (TTY/HCO)
711 in your service area
Physician Help Line
(Lucet)
Please call 855-339-9812
Primary Requirements
• Providers/Facilities must use an NPI number in billing.
• Unless present for the entire session, providers may not bill for services rendered
by interns and provisionally licensed providers.
• All Alabama providers MUST have a physical location in Alabama. Telehealth
only providers must also have a physical address in AL for each TIN
Authorizations
• No authorization is required for most office-based outpatient services, including
psychological or neuropsychological testing unless otherwise noted.
• Southern Company requires authorization for residential treatment,
Transcranial Magnetic Stimulation (TMS), and Repetitive Transcranial
Magnetic Stimulation (rTMS).
• Applied Behavior Analysis (ABA) therapy requires prior authorization for all
sessions.
• Precertification is required for all inpatient services.
• Precertification is required for partial hospitalization and intensive outpatient
services when required by the Member’s contract.
• Some products require a referral from the Member’s primary care physician prior
to treatment.
Benefits
• Online eligibility and benefits information is available
at https://providers.bcbsal.org/
• WebPass is Lucet’s online system that allows providers to access product
eligibility and benefit information. Lucet WebPass system is accessible
through Lucet's website, WebPass. To obtain a username and password
to access the WebPass system, please follow the instructions listed on the
website.
• If you have questions about Member benefits, please call Lucet Customer
Service at 1-855-339-8558.
Medical Necessity Appeals
Appeal Type
Timely Filing
Lucet Turn
Around Time
How to Submit a Request
Expedited
Appeal
Two (2) years
after denial is
rendered**
72 hours from
receipt of request
Phone: 800-248-2342
Standard
Appeal
Two (2) years
after denial is
rendered
30 calendar days
from receipt of
the
request
Online: WebPass
Phone: 800-248-2342
Fax: 816-237-2382
Mail: LUCET HEALTH
Attn: Appeals
PO Box 6729
Leawood, KS 66206-0729
*Excludes Medicare and FEP plans
**Medical necessity appeal inquiries for Medicare and Federal plans should be directed to Blue Cross
Blue Shield of Alabama at 800-248-2342.
***Member must currently be in treatment at the requested level of care, and urgency must be
demonstrated
Claims
Timely Filing
The timely filing of claims is 180 days.
All Blue Choice and EPS EDI Claims
Please work directly with your Practice Management System vendor or Clearinghouse
to obtain information on enrolling or setting up your system to submit Blue Choice and
all EPS claims to BCBSAL. Providers may work with their specific clearinghouse to set it
up correctly in their practice management system. Alternatively, Providers may work
directly with their practice management system vendor, even if they use a
clearinghouse because the practice management system vendor will coordinate the
setup for submitting Blue Choice and EPS claims to BCBSAL.
Please click the link for instructions about electronic funds transfers (EFT): Direct
Deposit/EFT Registration - provider.bcbsal.org
Change in Demographics
If you are an individually credentialed provider with Lucet and need to update your
demographic information with us, please complete the electronic update form
appropriate for your provider type. Forms are available on our website
at https://www.lucethealth.com/Providers. Select Blue Cross and Blue Shield of
Alabama under the ‘Choose your health plan’ drop-down box, then click the Profile
Updates box. If you have questions, please get in touch with Provider Relations at 888-
611-6285 or Providersupport@Lucethealth.com. Accurate demographic information
ensures timely referrals.
Medical Records
Medical records are to be provided upon request without charge.
Telemedicine
Telemedicine is a secure and HIPAA-compliant method of delivering behavioral health
services using interactive telecommunications when the member and the behavioral
health provider are not in the same physical location. The Member must have a covered
mental health benefit that permits Telemedicine for Providers to receive payment for
Telemedicine services.
Lucet considers telemedicine to aid in delivering behavioral health coverage using
interactive telecommunications when the member and behavioral health provider are
not in the same physical location. Telecommunications must be synchronous (live)
telemedicine service rendered via a real-time audio and video telecommunications
system. Effective 1/1/24, Alabama Providers can bill the telehealth audio-only codes
99441-99443. This must be reported when there is no visual component. See, for
example, the Telehealth Billing Guide For Providers for additional guidance.
Behavioral Health Providers can provide telemedicine services at a Consulting provider
site (distant site), a Referring provider site (originating site), or both.
• A Consulting provider site (distant site) is one at which services are provided to a
member not physically present with the behavioral health provider. Providers will
use the appropriate CPT codes for Telemedicine Behavioral Health.
• A Referring provider site (originating site) is one at which services are provided to
a member in an office of a provider using the originating site’s equipment to receive
Telemedicine Behavioral Health services with a provider in another location. The
originating site can bill BCBSAL claims for providing the equipment with the
appropriate Q code but not for the behavioral health services.
• All Alabama providers MUST have a physical location in Alabama. Telehealth
only providers must also have a physical address in AL for each TIN
Codes
All available fee schedule codes are appropriate for use by Behavioral Health Providers
if the service provided through Telemedicine can be done with the same quality as the
service provided in the office setting. Exceptions may apply during a Public Health
Emergency.
When billing for behavioral health services delivered via Telemedicine, use the
“95” or the “GT” modifier. Use Place of Service Code “02” or “10”.
Provider’s Responsibility:
Providers will choose a secure, HIPAA-compliant vendor and sign an attestation form
agreeing to meet all necessary telemedicine requirements before conducting
telemedicine services:
• Complete the Telemedicine Behavioral Health Services Provider Attestation form
• Meet the requirements outlined in the Telemedicine Behavioral Health Services
Provider Attestation form, including the ability to provide
all telemedicine sessions through secure, HIPAA-compliant technology.
• Carry Liability and malpractice insurance that covers telemedicine services.
Questions should be directed to your provider relations representative:
• Sherry Kitchens, RN, Clinical Service Coordinator: skitchens@lucethealth.com or
205-209-3743
• Nancy Thomas, LPC, Clinical Network Manager, nwthomas@lucethealth.com or
205-209-3742
Arkansas Blue Cross Blue Shield (ABCBS) Commercial HMO
and PPO
Precertification
(Lucet)
Please call 877-801-1159
or utilize WebPass
Organizational Determination
Benefit Inquiry
(Lucet)
Please call 877-801-1159
or utilize WebPass
Benefits and Eligibility
(Lucet)
Please call 877-801-1159
or utilize WebPass
Medical Necessity Appeals
(Lucet)
See chart below
Claims Inquiries
(ABCBS)
To find the ABCBS phone number, please check the
back of the member’s ID card or visit
https://www.arkansasbluecross.com/
Provider Relations
(ABCBS)
To find the ABCBS phone number, please check the
back of the member’s ID card or visit
https://www.arkansasbluecross.com/
Deaf or Hard of Hearing
(Arkansas Relay)
800-285-1131 (Voice)
800-285-1131 (TTY)
711 in your service area
Medical Necessity Appeals
(Lucet)
Please call 800-367-0406
* Applicable to Self-Funded groups
**Applicable to Fully-Insured Commercial and Exchange (excludes Medicare Adv, FEP, and Self-Funded
plans)
Primary Requirements
• Providers/Facilities must use an NPI number in billing.
• Unless present for the entire session, providers may not bill for services rendered
by interns and provisionally licensed providers.
Authorizations
• Authorization rules vary according to member benefits. Please call the number
on the back of the member’s ID card with questions.
Organizational Determinations/Benefit Inquiry
• For those services that don’t require prior authorization, we encourage providers
to submit an Organizational Determination/Benefit Inquiry instead. This form
replaces any former courtesy reviews or formal benefit inquiries.
• An Organization Determination/Benefit Inquiry is an optional process to
understand if a service meets medical necessity criteria.
• Arkansas Blue Cross will honor the decision(s) made on the Organizational
Determination/Benefit Inquiry
Benefits
• If you have questions about member benefits, please use provider WebPass or
call Lucet Customer Service at 877-801-1159.
Medical Necessity Appeals
Appeal Type
Timely Filing
Lucet Turn
Around Time
How to Submit a Request
Expedited
Appeal
180 days after
denial is
rendered
72 hours from
receipt of request
Phone: 800-248-2342
Standard
Appeal
180 days after
denial is
rendered
30 calendar days
from receipt of the
request
Online: WebPass
Phone: 800-248-2342
Fax: 816-237-2382
Mail: LUCET HEALTH
Attn: Appeals
PO Box 6729
Leawood, KS 66206-0729
*Excludes Medicare and FEP plans
**Medical necessity appeal inquiries for Medicare and Federal plans should be directed to Arkansas Blue
Cross Blue Shield. Please see the separate appendix sections on Arkansas Medicare and Federal
policies.
***Member must currently be in treatment at the requested level of care, and urgency must be
demonstrated
Claims
• Claims must meet timely filing requirements.
• For claims inquiries, please check the back of the member’s ID card or visit
https://www.arkansasbluecross.com/
• Electronic Claims – providers interested in filing electronic claims should use
payer ID – 00520.
• Paper Claims – Paper claims should be mailed to:
Arkansas Blue Cross and Blue Shield
P.O. Box 2181
Little Rock, AR 72203-2181
Medical Records
• Medical records are to be provided upon request without charge.
Telehealth
• Reimbursement for telehealth services is subject to plan guidelines.
Arkansas Blue Cross Blue Shield (ABCBS) Federal Employee
Program (FEP) (including State of Arkansas Employees)
Precertification
(Lucet)
Please call 877-801-1159
or utilize WebPass
Benefits and Eligibility
(Lucet)
Please call 877-801-1159
or utilize WebPass
Provider Relations
(Lucet)
Please call 888-611-6285, submit a support case to
Login (lucethealth.com), or email
Providersupport@Lucethealth.com.
Deaf or Hard of Hearing
(Arkansas Relay)
800-285-1131 (Voice)
800-285-1131 (TTY)
711 in your service area
Medical Necessity Appeals
(Lucet)
Please call 800-367-0406
Medical Necessity Appeals
(State of Arkansas)
Employee Appeals 800-484-8416
Appeals Fax 501-978-2916
Primary Requirements
• Providers/Facilities must use an NPI number in billing.
•
Authorizations
• Applied Behavior Analysis (ABA) therapy requires prior authorization for all
sessions.
• No authorization is required for outpatient services, including partial
hospitalization and intensive outpatient services.
• Precertification is required for all inpatient services, including residential.
• Prior authorization is required for residential services.
• No authorization is required for psychological or neuropsychological testing.
• State of Arkansas Employees: Authorization is required for ABA, inpatient,
residential, partial hospitalization, intensive outpatient services, and Transcranial
Magnetic Stimulation (TMS).
Timely Filing
• Timely filing of claims is 180 days.
Benefits
• ABCBS FEP department will quote benefits. If you have questions about
member benefits, please call FEP customer service at 1-800-482-6655.
Claims
• Claims must meet FEP/ABCBS filing requirements.
• Clean claims will be processed within 10 to 30 days. To check the status of a
claim, please call FEP customer service at 1-800-482-6655.
• Electronic Claims – providers interested in filing electronic claims should use
payer ID – 00520.
Paper Claims – Paper claims should be mailed to:
Arkansas Blue Cross Blue Shield FEP
P.O. Box 2181
Little Rock, AR 72203
• Arkansas Blue Cross FEP Customer Service: 1-800-482-6655
• Lucet Customer Service: Use Provider WebPass or call 800-367-0406
• All services must be billed in whole units. Partial units will not be paid.
• Paper Claims for Arkansas State Employees – Paper claims should be mailed
to:
Arkansas Blue Cross Blue Shield – Arkansas State Employees
PO Box 8069
Little Rock, AR 72203
• Electronic Claims for Arkansas State Employees– Providers interested in filing
electronic claims should use payer ID – 00520
• To check the status of claims for Arkansas State Employees, call 1-800-482-
8416
Change in Demographics
• Please provide 45 days advance notice of any planned availability or
demographic changes when possible. Contractually, you must notify us within
72 hours of changes to address, phone number, fax number, or email.
• To submit changes, please complete the electronic update form appropriate
for your provider type, which is available on our website
at https://www.lucethealth.com/Providers. Select Arkansas Blue Cross Blue
Shield under the ‘Choose your health plan’ drop-down box, then click
the Profile Updates box. If you have questions, please contact provider
relations at 888-611-6285. ARProviderRelations@LUCETHEALTH.com
Medical Records
• Medical records are to be provided upon request without charge.
Telehealth
• Reimbursement for telehealth services is subject to plan guidelines.
Arkansas Blue Cross Blue Shield (ABCBS) Medicare
Advantage (MA)
Precertification
(Lucet)
Please call 877-801-1159
or utilize WebPass
Benefits and Eligibility
(Lucet)
Please call 877-891-5196
or utilize WebPass
Claims Inquiries
(ABCBS)
Please call 800-287-4188
Provider Relations
(ABCBS)
Please call 877-359-1441
Deaf or Hard of Hearing
(Arkansas Relay)
800-285-1131 (Voice)
800-285-1131 (TTY)
711 in your service area
Medical Necessity Appeals
(ABCBS)
Please call 501-378-2025
Primary Requirements
• Providers/Facilities must use an NPI number in billing.
Authorizations
• Precertification is required for inpatient, partial hospitalization, intensive
outpatient services, and Transcranial Magnetic Stimulation (TMS).
• Residential is not a covered benefit for ABCBS MA.
• No authorization is required for outpatient care, psychological or
neuropsychological testing.
• Applied Behavior Analysis (ABA) is a covered benefit for ABCBS MA. ABA does
not require prior authorization for ABCBS MA.
• Out of Network authorization rules vary by group and plan.
Benefits
• If you have questions about member benefits, please use provider WebPass or
call Lucet Customer Service at 877-891-5196.
Claims
• Claims must meet timely filing requirements.
• For claims inquiries, call 877-345-5976
• Electronic Claims – providers interested in filing electronic claims should use
payer ID – 00520.
• Paper Claims – Paper claims should be mailed to:
Arkansas Blue Cross and Blue Shield
P.O. Box 2181
Little Rock, AR 72203-2181
Medical Records
• Medical records are to be provided upon request without charge.
Telehealth
• Reimbursement for telehealth services is subject to plan guidelines.
Walmart through Arkansas Blue Cross Blue Shield/Blue
Advantage Administrators (BAA)
Precertification
(Lucet)
Please call 877-709-6822
or utilize WebPass
Provider Relations
(Lucet)
Please call 888-611-6285, submit a support case to
Login (lucethealth.com), or email
Providersupport@Lucethealth.com.
Deaf or Hard of Hearing
(Arkansas Relay)
800-285-1131 (Voice)
800-285-1131 (TTY)
711 in your service area
Primary Requirements
• Providers/Facilities must use an NPI number in billing.
Authorizations
• Authorization is required for partial hospitalization and intensive outpatient
services.
• No authorization is required for routine outpatient services.
• Precertification is required for Inpatient and residential services.
• Authorization is required for psychological or neuropsychological testing,
Transcranial Magnetic Stimulation (TMS), and Outpatient ECT
• Applied Behavior Analysis (ABA) therapy requires prior authorization for all
sessions.
• Failure to obtain prior authorization may result in denial of payment.
Timely Filing
• Timely filing of claims is 365 days.
Benefits
• If you have questions about member benefits, please use provider WebPass or
call Lucet Customer Service at 1-877-709-6822.
Medical Necessity Appeals
Appeal Type
Timely Filing
Lucet Turn
Around Time
How to Submit a Request
Expedited
Appeal
Six (6) months
after denial is
rendered
72 hours from
receipt of request
Phone: 800-248-2342
Standard
Appeal
Six (6) months
after denial is
rendered
30 calendar days
from receipt of the
request
Online: WebPass
Phone: 800-248-2342
Fax: 816-237-2382
Mail: LUCET HEALTH
Attn: Appeals
PO Box 6729
Leawood, KS 66206-0729
*Member must currently be in treatment at the requested level of care, and urgency must be
demonstrated.
Claims
• Claims must meet ABCBS filing requirements.
• Clean claims will be processed within 10 to 30 days.
• Electronic Claims – providers interested in filing electronic claims should use
payer ID – 00520.
• Paper Claims – paper claims should be mailed to:
Blue Advantage Administrators
P.O. Box 1460
Little Rock, AR 72203
• Lucet Customer Service: 1-877-709-6822
• All services must be billed in whole units. Partial units will not be paid.
Medical Records
• Medical records are to be provided upon request without charge.
Telehealth
• Reimbursement for telehealth services is subject to plan guidelines.
Florida Blue PPO, including Medicare Advantage
Authorizations for
ABA Therapy
(Lucet)
Fax to 816-237-2372
Attn: FL ABA Request
Precertification
(Lucet)
Please call 877-801-1159
or utilize WebPass
Benefits and Eligibility
(Lucet)
Please call 877-801-1159
or utilize WebPass
Claims Inquiries
(Lucet)
Please call 877-801-1159
or utilize WebPass
Provider Relations
(Lucet)
Please call 888-611-6285, submit a support case to
Login (lucethealth.com), or email
Providersupport@Lucethealth.com.
Deaf or Hard of Hearing
(Florida Relay)
800-955-8770 (Voice)
800-955-8771 (TTY)
711 in your service area
Medical Necessity Appeals
Expedited and Member
(FLBCBS)
Please call 877-842- 9118
Medical Necessity Appeals
Standard
(Lucet)
Please call 877-801-1159
Authorizations
• Applied Behavior Analysis (ABA) requires authorization. Lucet will assign an
authorization reference number. (For authorizations related to Autism services,
please refer to the Applied Behavior Analysis for the Treatment of Autism
Spectrum Disorder Medical Policy under the Provider section
of www.lucethealth.com.) Failure to obtain authorization may result in denial of
payment. Refer to the member’s plan for specific benefits and authorization
requirements. The authorization must be in the name of the BCBA who will be
performing the services (e.g., 97151, 97155, 97156, 97157, 97158) or
overseeing the technicians performing the services (e.g., 97152, 97153, 97154).
Important Note: Some plans, including Medicare Advantage, do not have a
benefit for ABA services.
• Psychological/Neuropsychological testing does not require authorization unless
the proposed testing exceeds ten (10) hours per calendar year. Once the tenth
hour is billed, any subsequent hours will require submission of medical records to
determine medical necessity.
• For further information regarding Psychological/Neuropsychological testing
coverage, please see Florida Blue Medical Clinical Guidelines at
http://mcgs.bcbsfl.com/MCG?mcgId=01-95805-14&pv=false.”
• TMS & ECT require prior authorization. Please locate the request form
on www.lucethealth.com. Failure to obtain prior authorization may result in denial
of payment. Refer to the member’s plan for specific benefits and authorization
requirements.
Claims
• Please be advised: Florida Blue requires providers to utilize a type 2 NPI
number. If you are billing using a Tax ID number, you must register for a type 2
NPI number. You will NOT have to register for a Type 2 NPI number if you are
billing using your Social Security number.
• To avoid payment delays and or claim denials, please access the
following link to register for your type 2 NPI
number: https://nppes.cms.hhs.gov/NPPES/Welcome.do.
• Using your new group/type 2 NPI number in the billing process
• The group/type 2 NPI number will be used as the “billing provider” on a claim
• The individual NPI number will be used as the “rendering provider” on a claim
• Claims must be filed within 180 days from the date of service to meet timely filing
requirements.
• Clean claims will be processed within 10 to 30 days. To check the status of a
claim, please check Availity.
• Claims must be submitted electronically using payer ID – 00590.
• If no method is available for submitting an electronic claim, Lucet may waive the
electronic submission requirement.
• In-state and Out-of-state (BlueCard) claims review requests must be submitted
through the Availity secure provider portal.
• All services must be billed in whole units. Partial units will not be paid.
• All higher levels of care must be billed based on the number of days authorized
for proper benefit and claim adjudication. See Florida Blue billing guidelines on
the floridablue.com website provider resources.
• For commercial programs only, services provided by provisionally licensed
clinicians must be billed under the qualified supervisor’s NPI in accordance with
all Florida billing and licensing requirements [CS1] per Ch 490 & 491 Fla. Stat.
(2022). The following HCPCS modifiers shall be used as appropriate:
• GC- Service has been performed in Part by a Resident under the Direction
of a Teaching Physician
• HO- The rendering provider has the highest educational attainment of a
master’s degree.
• HP- The rendering provider has the highest educational attainment of a
doctoral degree.
Lucet Navigate and Connect Platform
In-network FLB providers have the opportunity to participate at no cost in our best-in-
class scheduling and measurement-based care technology program.
Every year, Lucet receives thousands of calls from Florida Blue members seeking
referrals to behavioral health providers. Our goal is to connect these members to high-
quality mental health treatment in a timely fashion. Our technology platform, Lucet,
allows our call center representatives and care managers to assist members by directly
scheduling appointments with in-network providers. To truly understand this service's
benefits to members and providers, watch this short video, which spotlights one of our
contact center representatives as she speaks about the impact of the direct scheduling
program.
As the program grows, we seek more providers to join this initiative. Participation in
the program offers multiple benefits, including:
• Tailored referrals for patients, curated for your practice
• Hassle-free appointment scheduling, including appointment reminders
Digital assessments that identify key issues in advance of treatment sessions
and support measurement-based care
If you want to learn more and would like to speak with a Lucet team member, please fill
out the Contact Us form.
Medical Necessity Appeals
Appeal Type
Timely Filing
Lucet Turn
Around Time
How to Submit a Request
Expedited
Appeal
180 days after
denial is
rendered
72 hours from
receipt of request
Phone (FLBCBS): 877-842-9118
Standard
Appeal
180 days after
denial is
rendered
30 calendar days
from receipt of the
request
Online: WebPass
Phone: 800-248-2342
Fax: 816-237-2382
Mail: LUCET HEALTH
Attn: Appeals
PO Box 6729
Leawood, KS 66206-0729
* Medical necessity appeal inquiries for federal plans should be directed to Florida Blue. Please see the
separate appendix section on Florida Blue Federal Employee Program policies. Medical necessity appeal
inquiries for Medicare Advantage Plans should be directed to Florida Blue at 877-842-9118.
**Member must currently be in treatment at the requested level of care, and urgency must be
demonstrated
Notifications/Certification
• Notification/Certification is required for all Inpatient, Residential, Partial
Hospitalization, and Intensive Outpatient Services. Some self-funded Plans may
not have this requirement. Important Note: Medicare Advantage has no benefit
for Residential Services.
For more information about the Florida Provider Telephonic Review Process,
please click and read the guidelines here.
Benefits
• Benefits vary by group and plan. For Behavioral Health and Substance use
benefit validation, providers are encouraged to contact the Lucet Contact Center
at 866 730-5006.
Change in Demographics
• Changes must be submitted within 72 hours of a change related to addresses,
phone numbers, fax numbers, or email; however, please provide 45 days' notice
of any planned availability or demographic changes when possible.
• To submit changes, please complete the electronic update form appropriate for
your provider type, which is available on our website
at https://www.lucethealth.com/Providers. Select Florida Blue under the ‘Choose
your health plan’ drop-down box, then click the Profile Updates box. If you have
questions, please contact Provider Relations at 888-611-6285
or Providersupport@Lucethealth.com.
Medical Records
• Medical records are to be provided upon request without charge.
Telehealth
• Reimbursement for telehealth services is subject to plan guidelines.
Florida Blue HMO, including Medicare Advantage
and BlueMedicare Classic Plus HMO, available in
Hillsborough and Palm Beach Counties,
Authorizations for
ABA Therapy
(Lucet)
Fax to 816-237-2372
Attn: FL ABA Request
Precertification
(Lucet)
Please call 877-801-1159
or utilize WebPass
Benefits and Eligibility
(Lucet)
Please call 877-801-1159
or utilize WebPass
Claims Inquiries
(Lucet)
Please call 877-801-1159
or utilize WebPass
Provider Relations
(Lucet)
Please call 888-611-6285, submit a support case to
Login (lucethealth.com), or email
Providersupport@Lucethealth.com.
Deaf or Hard of Hearing
(Florida Relay)
800-955-8770 (Voice)
800-955-8771 (TTY)
711 in your service area
Medical Necessity Appeals
Expedited and Member
(FLBCBS)
Please call 877-842- 9118
Medical Necessity Appeals
Standard
(Lucet)
Please call 877-801-1159
Authorizations
• ABA requires prior authorization from the first visit. Lucet will assign an
authorization reference number. (For authorizations related to Autism services,
please refer to the Applied Behavior Analysis for the Treatment of Autism
Spectrum Disorder Medical Policy located under the provider section
of www.lucethealth.com) Failure to obtain prior authorization may result in denial
of payment. Refer to the member’s plan for specific benefits and authorization
requirements. Note: Medicare Advantage has no benefit for Autism services.
• Authorization is required for all Inpatient, Residential, Partial Hospitalization, and
Intensive Outpatient services (including ABA therapy). Note: some self-funded
plans may not have this requirement. Note: Medicare Advantage has no benefit
for Residential Services.
• Psychological/Neuropsychological testing does not require authorization unless
the proposed testing exceeds ten (10) hours per calendar year. Once the tenth
hour is billed, any subsequent hours will require submission of medical records to
determine medical necessity.
• For further information regarding Psychological/Neuropsychological testing
coverage, please see Florida Blue Medical Clinical Guidelines.
• TMS and ECT require authorization from the first visit. Please locate the request
form on www.lucethealth.com. Failure to obtain prior authorization may result in
denial of payment. Refer to the member’s plan for specific benefits and
authorization requirements.
Medical Necessity Appeals
Appeal Type
Timely Filing
Lucet Turn
Around Time
How to Submit a Request
Expedited
Appeal
180 days after
denial is
rendered
72 hours from
receipt of request
Phone (FLBCBS): 877-842-9118
Standard
Appeal
180 days after
denial is
rendered
30
calendar days
from receipt of the
request
Online: WebPass
Phone: 800-248-2342
Fax: 816-237-2382
Mail: LUCET HEALTH
Attn: Appeals
PO Box 6729
Leawood, KS 66206-0729
* Medical necessity appeal inquiries for federal plans should be directed to Florida Blue. Please see the
separate appendix section on Florida Blue Federal Employee Program policies. Medical necessity appeal
inquiries for Medicare Advantage Plans should be directed to Florida Blue at 877-842-9118.
**Member must currently be in treatment at the requested level of care, and urgency must be
demonstrated
Claims
• Please be advised: Florida Blue requires providers to utilize a type 2 NPI
number. If you are billing using a Tax ID number, you must register for a type 2
NPI number. You will NOT have to register for a Type 2 NPI number if you are
billing using your Social Security number.
• To avoid payment delays and or claim denials, please access the
following link to register for your type 2 NPI number:
https://nppes.cms.hhs.gov/NPPES/Welcome.do.
• Use your new group/type 2 NPI number in the billing process
• The group/type 2 NPI number will be used as the “billing provider” on a claim
• The individual NPI number will be used as the “rendering provider” on a claim
• Claims must be filed within 180 days from the date of service to meet timely filing
requirements.
• Clean claims will be processed within 10 to 30 days. To check the status of a
claim, please check Availity
• Claims must be submitted electronically using payer ID – 00590.
• If no method is available to submit an electronic claim, Lucet may waive the
electronic submission requirement.
• In-state and Out-of-state (BlueCard) claims review requests must be submitted
through the Availity secure provider portal.
• All services must be billed in whole units. Partial units will not be paid.
• All higher levels of care must be billed based on the number of days authorized
for proper benefit and claim adjudication. See Florida Blue billing guidelines on
the floridablue.com website, which provides resources
Benefits
• Varies by group
• No out-of-network benefit unless a group has a Point of Service (POS) Rider
• For Behavioral Health and Substance use benefit validation, providers are
encouraged to contact 866 730-5006.
Change in Demographics
• Please provide 45 days advance notice of any planned availability or
demographic changes when possible. Contractually, you must notify us within 72
hours of changes to address, phone number, fax number, or email.
• To submit changes, please complete the electronic update form appropriate for
your provider type, which is available on our website
at https://www.lucethealth.com/Providers. Select Florida Blue under the ‘Choose
your health plan’ drop-down box, then click the Profile Updates box. If you have
questions, please contact Provider Relations at 888-611-6285
or Providersupport@Lucethealth.com.
Medical Records
• Medical records are to be provided upon request without charge.
Telehealth
• Reimbursement for telehealth services is subject to plan guidelines.
Florida Blue Federal Employee Program (FEP)
Authorizations for
ABA Therapy
(Lucet)
Fax to 816-237-2372
Attn: FL ABA Request
Precertification
(Lucet)
Please call 877-801-1159
or utilize WebPass
Benefits and Eligibility
(Lucet)
Please call 877-801-1159
or utilize WebPass
Claims Inquiries
(Lucet)
Please call 877-801-1159
or utilize WebPass
Provider Relations
(Lucet)
Please call 888-611-6285, submit a support case to
Login (lucethealth.com), or email
Providersupport@Lucethealth.com.
Deaf or Hard of Hearing
(Florida Relay)
800-955-8770 (Voice)
800-955-8771 (TTY)
711 in your service area
Reconsideration/ Inquiries
(FLBCBS)
Please call 877-842- 9118
The Federal Employee Program® (FEP) has announced the creation of the Blue
Focus benefit plan, effective January 1, 2019. FEP Blue Focus will utilize the same
provider network as the existing FEP Standard and Basic Options. To learn more about
this FEP plan, click here.
Claims
• Please be advised: Florida Blue requires providers to utilize a type 2 NPI
number. If you are billing using a Tax ID number, you must register for a type 2
NPI number. You will NOT have to register for a Type 2 NPI number if you are
billing using your Social Security number.
• To avoid payment delays and or claim denials, please access the
following link to register for your type 2 NPI
number: https://nppes.cms.hhs.gov/NPPES/Welcome.do.
• Use your new group/type 2 NPI number in the billing process
• The group/type 2 NPI number will be used as the “billing provider” on a claim
• The individual NPI number will be used as the “rendering provider” on a claim
• Claims must be filed within 180 days from the date of service to meet timely filing
requirements.
• Clean claims will be processed within 10 to 30 days. To check the status of a
claim, please check Availity
• Claims must be submitted electronically using payer ID – 00590.
• If no method is available for submitting an electronic claim, Lucet may waive the
electronic submission requirement.
• In-state and Out-of-state (BlueCard) claims review requests must be submitted
through the Availity secure provider portal.
• All services must be billed in whole units. Partial units will not be paid.
• All higher levels of care must be billed based on the number of days authorized
for proper benefit and claim adjudication. See Florida Blue billing guidelines on
the floridablue.com website, which provides resources
Certification
• Prior certification is required for Applied Behavior Analysis (ABA).
• No certification is required for outpatient services.
• Exception: FEP Focus policy requires authorization for IOP/PHP when the
setting is a Residential facility
• Certification is required for all Inpatient services.
• Precertification is required for Residential Treatment.
• Psychological/Neuropsychological testing does not require authorization unless
the proposed testing exceeds ten (10) hours per calendar year. Once the tenth
hour is billed, any subsequent hours will require submission of medical records to
determine medical necessity.
• For further information regarding Psychological/Neuropsychological testing
coverage, please see Florida Blue Medical Clinical Guidelines at
http://mcgs.bcbsfl.com/MCG?mcgId=01-95805-14&pv=false.
• TMS and ECT require certification from the first visit. Please locate the request
form on www.lucethealth.com. Failure to obtain certification may result in denial
of payment. Refer to the member’s plan for specific benefits and certification
requirements.
Benefits
• For Behavioral Health and Substance use benefit validation, providers must
contact the Lucet Contact Center at 866 730-5006.
Change in Demographics
• Please provide 45 days advance notice of any planned availability or
demographic changes when possible. Contractually, you must notify us within 72
hours of changes to address, phone number, fax number, or email.
• To submit changes, please complete the electronic update form appropriate for
your provider type, which is available on our website
at https://www.lucethealth.com/Providers. Select Florida Blue under the ‘Choose
your health plan’ drop-down box, then click the Profile Updates box. If you have
questions, please contact Provider Relations at 888-611-6285
or Providersupport@Lucethealth.com.
Medical Records
• Medical records are to be provided upon request without charge.
Telehealth
• Teladoc is the telehealth vendor for FEP members. Providers must be contracted
with Teladoc to render telehealth services.
• Florida Blue Virtual Visits are available to FEP members at the office cost share
rate and must be billed by participating providers.
Florida Blue Medicare Preferred HMO
Outpatient Authorizations
(Lucet)
No authorization is required. Outpatient services may be
reviewed retrospectively.
Precertification
(Lucet)
Please call 877-801-1159
or utilize WebPass
Benefits and Eligibility
(Lucet)
Please call 877-801-1159
or utilize WebPass
Claims Inquiries
(Lucet)
Please call 877-801-1159
or utilize WebPass
Provider Relations
(Lucet)
Please call 888-611-6285, submit a support case to
Login (lucethealth.com), or email
Providersupport@Lucethealth.com.
Deaf or Hard of Hearing
(Florida Relay)
800-955-8770 (Voice)
800-955-8771 (TTY)
711 in your service area
Medical Necessity Appeal
(FLBCBS)
Please call 877-842- 9118
Authorizations
• No authorization is required for outpatient services
• Authorization is required for all inpatient, partial hospitalization, and intensive
outpatient services. Authorization is required for TMS and ECT. Please locate the
form on www.lucethealth.com
• Psychological/Neuropsychological testing does not require authorization unless
the proposed testing exceeds ten (10) hours per calendar year. Once the tenth
hour is billed, any subsequent hours will require submission of medical records to
determine medical necessity.
• For further information regarding Psychological/Neuropsychological testing
coverage, please see Florida Blue Medical Clinical Guidelines at
http://mcgs.bcbsfl.com/MCG?mcgId=01-95805-14&pv=false.”
Benefits
• Contact Lucet toll-free at 1-866-730-5006
• Benefits vary by group and plan
• Residential services are not covered
Claims
• Please be advised: Florida Blue requires providers to utilize a type 2 NPI
number. If you are billing using a Tax ID number, you must register for a type 2
NPI number. You will NOT have to register for a Type 2 NPI number if you are
billing using your Social Security number.
• To avoid payment delays and or claim denials, please access the
following link to register for your type 2 NPI
number: https://nppes.cms.hhs.gov/NPPES/Welcome.do.
• Use your new group/type 2 NPI number in the billing process
• The group/type 2 NPI number will be used as the “billing provider” on a claim
• The individual NPI number will be used as the “rendering provider” on a claim
• Claims must be filed within 180 days from the date of service to meet timely filing
requirements.
• Clean claims will be processed within 10 to 30 days. To check the status of a
claim, please check Availity
• Claims must be submitted electronically using payer ID – 00590.
• If no method is available for submitting an electronic claim, Lucet may waive the
electronic submission requirement.
• In-state and Out-of-state (BlueCard) claims review requests must be submitted
through the Availity secure provider portal.
• All services must be billed in whole units. Partial units will not be paid.
• All higher levels of care must be billed based on the number of days authorized
for proper benefit and claim adjudication. See Florida Blue billing guidelines on
the floridablue.com website, which provider resources
Change in Demographics
• Please provide 45 days advance notice of any planned availability or
demographic changes when possible. Contractually, you must notify us within 72
hours of changes to address, phone number, fax number, or email.
• To submit changes, please complete the electronic update form appropriate for
your provider type, which is available on our website
at https://www.lucethealth.com/Providers. Select Florida Blue under the ‘Choose
your health plan’ drop-down box, then click the Profile Updates box. If you have
questions, please contact Provider Relations at 888-611-6285
or Providersupport@Lucethealth.com.
Medical Records
• Medical records are to be provided upon request without charge.
Telehealth
• Reimbursement for telehealth services is subject to plan guidelines.
Blue Cross Blue Shield of Kansas
Additional provider information can be found at the following links on the BCBSKS
website, or you may contact your BCBSKS Provider Representative.
Plan Name
BCBSKS PPO BCBSKSEPO BSBSKS SOK BCBSKS FEP
BCBSKS
Medicare
Prior
Authorization
Inpatient
Precertification
Requests
Lucet 800-952-
5906 or
electronically
on
WebPass
Lucet 800-952-
5906 or
electronically
on
WebPass
Lucet 800-952-
5906 or
electronically
on
WebPass
Inpatient only
Lucet 800-952-
5906 or
electronically
on
WebPass
Lucet 800-589-
1635 or
electronically
on
WebPass
Prior
authorization
RTC
Lucet 800-952-
5906 or
electronically
on WebPass
Lucet 800-952-
5906 or
electronically
on WebPass
No Benefits
Lucet completes
enrollment in
CM (preferred
by not required)
Submit to HP
Lucet 800-589-
1635 or
electronically
on WebPass
Prior
Authorization
rTMS
HP process
HP process
HP process
HP process
Lucet 800-589-
1635 or
electronically
on WebPass
Prior
authorization
ABA
Lucet
Fax 816-237-
2372 or Phone
877-563-9347
or electronically
on WebPass
Lucet
Fax 816-237-
2372 or Phone
877-563-9347
or electronically
on WebPass
Lucet
Fax 816-237-
2372 or Phone
877-563-9347 or
electronically
on WebPass
Lucet
Fax 816-237-
2372 or Phone
877-563-9347
or electronically
on WebPass
N/A
Prior
authorization of
any other OP
service
Effective June
3, 2022, No
authorization is
required. Lucet
Effective June
6, 2022, No
authorization
required for
ECT,
Psychological
testing
Effective June
3, 2022, No
authorization is
required. Lucet
Effective June
6, 2022, No
authorization
required for
ECT,
Psychological
testing
Effective June 3,
2022, No
authorization is
required for IOP
or Partial Day
Services Lucet
Effective June 6,
2022, No
authorization is
required for ECT,
Psychological
testing.
No authorization
required
No authorization
required
Benefits,
Eligibility, Claims
Inquiries
BCBSKS 800-
432-3990
BCBSKS 800-
432-3990
BCBSKS 800-
432-3990
BCBSKS 800-
432-0379
BCBSKS 800-
240-0577
Other inquiries
Lucet 800-952-
5906
Lucet 800-952-
5906
Lucet 800-952-
5906
Lucet 800-952-
5906
Lucet 800-589-
1635
Provider
relations
BCBSKS 800-
432-3587
BCBSKS 800-
432-3587
BCBSKS 800-
432-3587
BCBSKS 800-
432-3587
BCBSKS 800-
432-3587
Deaf/Hard of
Hearing
Kansas Relay
Services 800-
766-3777
Kansas Relay
Services 800-
766-3777
Kansas Relay
Services 800-
766-3777
Kansas Relay
Services 800-
766-3777
Kansas Relay
Services 800-
766-3777
Member or
Provider Appeals
BCBSKS 800-
432-3990
BCBSKS 800-
432-3990
BCBSKS 800-
432-3990
BCBSKS 800-
432-3990
BCBSKS 800-
432-3990
Professional Provider Manuals
• https://www.bcbsks.com/documents/professional-provider-manual
Institutional Provider Manuals
• https://www.bcbsks.com/providers/institutional/resources
• Note: To access the Institutional Provider Manual, follow the offsite link and log in
to your secured Blue Access portal.
Medicare Advantage Provider Policies and Procedures
• https://www.bcbsks.com/providers/medicare-advantage
Blue Cross Blue Shield of Kansas City (Blue KC) Blue Care
HMO
Prior Authorizations
(Lucet)
Please call 800-528-5763
or utilize WebPass
Precertification
(Lucet)
Please call 800-528-5763
or utilize WebPass
Benefits and Eligibility
(Lucet)
Please call 800-528-5763
or utilize WebPass
Claims Inquiries
(Lucet)
Please call 833-964-6338
or utilize WebPass
Provider Relations
(Lucet)
Please call 888-611-6285, submit a support case to
Login (lucethealth.com), or email
Providersupport@Lucethealth.com.
Deaf or Hard of Hearing
(Kansas Relay)
800-766-3777 (Voice)
800-766-3777 (TTY)
711 in your service area
Deaf or Hard of Hearing
(Missouri Relay)
800-735-0135 (Voice)
800-735-2966 (TTY)
711 in your service area
Medical Necessity Appeals
Expedited
(Lucet)
Please call 800-528-5763
Medical Necessity Appeals
Standard
(Lucet)
Please utilize WebPass
Primary Requirements
• Providers must have a Blue KC Provider number. This is assigned after
credentialing is complete. If you do not already have an 8-digit Blue KC Provider
ID, please get in touch with customer service at 833-964-6338. The services
rendered by interns or provisionally licensed providers may bill as themselves as
out of network.
• Providers/Facilities must use an NPI number in billing.
• For face-to-face services, the provider must be licensed in the state where the
service is delivered, regardless of whether that is an office, home, or other
location.
Authorizations
• Prior authorization is required for all inpatient, residential, TMS, ECT,
psychological/neuropsychological testing, and ABA services.
• Failure to obtain prior authorization may result in denial of payment. Refer to the
member’s plan for specific benefits and authorization requirements.
• Outpatient professional services do not require authorization.
• No authorization is required for partial hospitalization and intensive outpatient
services. These services may be reviewed retrospectively to ensure they meet
the criteria for medical necessity.
• Applied Behavior Analysis (ABA) therapy requires prior authorization for all
sessions. For authorizations related to autism services, please refer to the policy
entitled “Applied Behavior Analysis for the Treatment of Autism Spectrum
Disorder Medical Policy,” located under the provider section of
www.lucethealth.com
• For authorizations related to testing, please refer to instructions on the
psychological testing request form in the provider section of
www.lucethealth.com.
o Psychological testing requires prior authorization after five hours of
testing.
o Neuropsychological testing requires prior authorization after eight hours
of testing.
• For authorizations related to TMS, please refer to instructions on the initial and
continuation treatment request forms and see our medical policy for this therapy
in the provider section of www.lucethealth.com.
Timely Filing
• Timely filing of claims is 180 days.
Benefits
• If you have questions about member benefits, please use provider WebPass or
call Lucet Customer Service at 833-964-6338.
• Blue KC’s automated system, “Blue Touch,” will walk you through the process
to obtain eligibility and benefits information. You will need your Blue KC
Provider number, the member’s ID number, and date of birth. The phone
number for Blue Touch is 816-395-3929. Online eligibility and benefits
information is available at http://www.bluekc.com/. Click on the “Provider”
icon.
• Blue KC may also be contacted at 816-395-2222.
Medical Necessity Appeals
Appeal Type
Timely Filing
Lucet Turn
Around Time
How to Submit a Request
Expedited
Appeal
180 days after
denial is
rendered
72 hours from
receipt of request
Phone: 833-964-6338
Standard
Appeal
180 days after
denial is
rendered
30 calendar days
from receipt of the
request
Online: WebPass
Phone: 800-248-2342
Fax: 816-237-2382
Mail: LUCET HEALTH
Attn: Appeals
PO Box 6729
Leawood, KS 66206-0729
*Excludes Medicare and FEP plans.
**Medical necessity appeal inquiries for Medicare and Federal plans should be directed towards Blue KC.
Please see the separate appendix sections on Blue KC Medicare and Federal policies.
***Member must currently be in treatment at the requested level of care, and urgency must be
demonstrated
Claims
• Blue KC will only accept claims via electronic billing. Use payer ID - 47171
• Blue KC Customer Service: 1-800-456-3759
• Lucet Customer Service: 833-964-6338
• All services must be billed in whole units. Partial units will not be paid.
Change in Demographics
• Please provide 45 days advance notice of any planned availability or demographic
changes when possible. Contractually, you must notify us within 72 hours of
changes to address, phone number, fax number, or email.
• To submit changes, please complete the electronic update form appropriate for
your provider type, which is available on our website
at https://www.lucethealth.com/Providers. Select Blue KC under the ‘Choose your
health plan’ drop-down box, then click the Profile Updates box. If you have
questions, please get in touch with Provider Relations at 888-611-6285
or KCProviderRelations@lucethealth.com
Medical Records
• Medical records are to be provided upon request without charge.
Telehealth
• Reimbursement for telehealth services is subject to plan guidelines
Blue Cross Blue Shield of Kansas City (Blue KC) Medicare
Prior Authorizations
(Lucet)
Please call 800-528-5763
or utilize WebPass
Precertification
(Lucet)
Please call 800-528-5763
or utilize WebPass
Benefits and Eligibility
(Blue KC)
Please call 866-508-7140
Claims Inquiries
(Lucet)
Please call 833-964-6338
or utilize WebPass
Provider Relations
(Lucet)
Please call 888-611-6285, submit a support case to
Login (lucethealth.com), or email
Providersupport@Lucethealth.com.
Deaf or Hard of Hearing
(Kansas Relay)
800-766-3777 (Voice)
800-766-3777 (TTY)
711 in your service area
Deaf or Hard of Hearing
(Missouri Relay)
800-735-0135 (Voice)
800-735-2966 (TTY)
711 in your service area
Medical Necessity Appeals
(Blue KC)
Please call 866-508-7140
Primary Requirements
• Providers must have a Blue KC Provider number. This is assigned after
credentialing is complete. If you do not already have an 8-digit Blue KC Provider
ID, please get in touch with customer service at 1-866-508-7140.The services
rendered by interns or provisionally licensed providers may bill as themselves as
out-of-network
• Providers/Facilities must use an NPI number in billing.
• For face-to-face services, the provider must be licensed in the state where the
service is delivered, regardless of whether that is an office, home, or other
location.
Authorizations
• Prior authorization is required for inpatient, Partial Hospital Program, and
Intensive Outpatient
• Failure to obtain prior authorization may result in denial of payment. Refer to the
member’s plan for specific benefits and authorization requirements.
• Precertification is not required for outpatient professional services.
• Medical necessity criteria may be found at www.lucethealth.com
Timely Filing
• Timely filing of claims is 365 days from the date of service or discharge.
Benefits
• Lucet will not quote benefits. If you have any questions about member benefits,
please call Blue KC Medicare customer service at 866-508-7140
Claims
• Blue KC will only accept claims via electronic billing. Use payer ID – 47171
o Electronic Claims – for more information on filing electronic claims, please
refer to www.bluekc.com or www.ask-edi.com.
• Blue KC Provider Hotline:1-800-456-3759
• Lucet Customer Service: 833-964-6338
• All services must be billed in whole units. Partial units will not be paid.
Change in Demographics
• Please provide 45 days advance notice of any planned availability or
demographic changes when possible. Contractually, you must notify us within 72
hours of changes to address, phone number, fax number, or email.
• To submit changes, please complete the electronic update form appropriate for
your provider type, which is available on our website
at https://www.lucethealth.com/Providers. Select Blue KC under the ‘Choose
your health plan’ drop-down box, then click the Profile Updates box. If you have
questions, please get in touch with Provider Relations at 888-611-6285
or KCProviderRelations@lucethealth.com
Medical Records
• Medical records are to be provided upon request without charge.
Telehealth
• Reimbursement for telehealth services is subject to plan guidelines.
Blue Cross Blue Shield of Kansas City (Blue KC) Preferred
Care, Preferred-Care Blue, BlueSelect & BlueSelect Plus
PPO, Affordable Care Act
Prior Authorizations
(Lucet)
Please call 800-528-5763
or utilize WebPass
Precertification
(Lucet)
Please call 800-528-5763
or utilize WebPass
Benefits and Eligibility
(Blue KC)
Please call 866-508-7140
Claims Inquiries
(Lucet)
Please call 833-964-6338
or utilize WebPass
Provider Relations
(Lucet)
Please call 888-611-6285, submit a support case to
Login (lucethealth.com), or email
Providersupport@Lucethealth.com.
Deaf or Hard of Hearing
(Kansas Relay)
800-766-3777 (Voice)
800-766-3777 (TTY)
711 in your service area
Deaf or Hard of Hearing
(Missouri Relay)
800-735-0135 (Voice)
800-735-2966 (TTY)
711 in your service area
Medical Necessity Appeals
(Lucet)
Please call 800-528-5763
or utilize WebPass
Primary Requirements
• Providers must have a Blue KC Provider number. This is assigned after
credentialing is complete. If you do not already have an 8-digit Blue KC Provider
ID, please get in touch with customer service at 1-800-456-3759. The services
rendered by interns or provisionally licensed providers may bill as themselves as
out-of-network
• Providers/Facilities must use an NPI number in billing.
• For face-to-face services, the provider must be licensed in the state where the
service is delivered, regardless of whether that is an office, home, or other
location.
Authorizations
• Prior authorization is required for all inpatient, residential, TMS, ECT,
psychological/neuropsychological testing, and ABA services.
Failure to obtain prior authorization may result in denial of payment.
Refer to the member’s plan for specific benefits and authorization
requirements.
• Outpatient professional services do not require authorization.
• No authorization is required for partial hospitalization (PHP) and intensive
outpatient services (IOP), except as indicated below. These services may be
reviewed retrospectively to ensure they meet the criteria for medical necessity.
• The following plans require prior authorization for the specified services:
ACA: Individual members require prior authorization for PHP and IOP
services.
You can identify ACA Individual members by their member ID, which begins
with the prefix YBD, YBG, YJJ, YBS, or YJT.
JAA groups
• Applied Behavior Analysis (ABA) therapy requires prior authorization for all
sessions.” For authorizations related to Autism services, please refer to the
Applied Behavior Analysis for the Treatment of Autism Spectrum Disorder
Medical Policy located under the provider section of www.lucethealth.com
• Psychological testing requires prior authorization. Prior authorization is required
for neuropsychological testing. For authorizations related to testing, please refer
to instructions on the psychological testing request form located under the
provider section of www.lucethealth.com.
• Transcranial Magnetic Stimulation (TMS) requires prior authorization. For
authorizations related to TMS, please refer to the instructions on the initial and
continuation treatment request forms and see our medical policy for this
therapy.
Timely Filing
• Timely filing of claims is 180 days.
Benefits
• If you have questions about member benefits, please use provider WebPass or
call Lucet Customer Service at 833-964-6338.
• Blue KC’s automated system, “Blue Touch,” will walk you through the process
to obtain eligibility and benefits information. You will need your Blue KC
Medical Necessity Appeals
(Excludes Medicare and FEP plans) *
Appeal Type
Timely Filing
Lucet Turn
Around Time
How to Submit a Request
Expedited
Appeal
180 days after
denial is
rendered
72 hours from
receipt of request
Phone: 833-964-6338
Standard
Appeal
180 days after
denial is
rendered
30 calendar days
from receipt of the
request
Online: WebPass
Phone: 800-248-2342
Fax: 816-237-2382
Mail: LUCET HEALTH
Attn: Appeals
PO Box 6729
Leawood, KS 66206-0729
*Medical necessity appeal inquiries for Medicare and Federal plans should be directed to Blue KC.
Please see the separate appendix sections on Blue KC Medicare and Federal policies.
**Member must currently be in treatment at the requested level of care, and urgency must be
demonstrated
Claims
• Blue KC will only accept claims via electronic billing. Use payer ID - 47171
• Blue KC Customer Service:1-800-456-3759
• Lucet Customer Service: 833-964-6338
• All services must be billed in whole units. Partial units will not be paid.
Change in Demographics
• Please provide 45 days advance notice of any planned availability or
demographic changes when possible. Contractually, you must notify us within 72
hours of changes to address, phone number, fax number, or email.
• To submit changes, please complete the electronic update form appropriate for
your provider type, which is available on our website
at https://www.lucethealth.com/Providers. Select Blue KC under the ‘Choose
your health plan’ drop-down box, then click the Profile Updates box. If you have
questions, please get in touch with Provider Relations at 888-611-6285
or KCProviderRelations@lucethealth.com
Medical Records
• Medical records are to be provided upon request without charge.
Telehealth
• Reimbursement for telehealth services is subject to plan guidelines.
Blue Cross Blue Shield of Kansas City (Blue KC) Federal
Employee Program (FEP)
Prior Authorizations
(Lucet)
Please call 800-528-5763
or utilize WebPass
Precertification
(Lucet)
Please call 800-528-5763
or utilize WebPass
Benefits and Eligibility
(Lucet)
Please call 800-528-5763
or utilize WebPass
Claims Inquiries
(Lucet)
Please call 800-528-5763
or utilize WebPass
Provider Relations
(Lucet)
Please call 888-611-6285, submit a support case to
Login (lucethealth.com), or email
Providersupport@Lucethealth.com.
Deaf or Hard of Hearing
(Kansas Relay)
800-766-3777 (Voice)
800-766-3777 (TTY)
711 in your service area
Deaf or Hard of Hearing
(Missouri Relay)
800-735-0135 (Voice)
800-735-2966 (TTY)
711 in your service area
Medical Necessity Appeals
(Blue KC)
Please call 816-395-2500
Primary Requirements
• Providers must have a Blue KC Provider ID number. Blue KC will assign a
provider ID number after credentialing is complete. To obtain a Blue KC Provider
ID number, please get in touch with Blue KC customer service at 1-816-395-
3678. The services rendered by interns or provisionally licensed providers may
bill as themselves as out-of-network
• Providers/Facilities must use an NPI number in billing.
• For face-to-face services, the provider must be licensed in the state where the
service is delivered, regardless of whether that is an office, home, or other
location.
Authorizations
• Prior authorization is required for inpatient services.
• Prior authorization is required for residential services.
• Failure to obtain prior authorization may result in denial of payment. Refer to the
member’s plan for specific benefits and authorization requirements.
• No authorization is required for partial hospitalization, intensive outpatient,
psychological/neuropsychological testing, or OP ECT services. These services
may be reviewed retrospectively to ensure medical necessity.
• Prior authorization is required for Applied Behavior Analysis (ABA), inpatient and
residential.
• No authorization is required for psychological or neuropsychological testing.
These services may be reviewed retrospectively to ensure medical necessity.
Timely Filing
• Timely filing of claims is 180 days.
Benefits
• If you have questions about member benefits, please use provider WebPass or
call Lucet Customer Service at 1-800-528-5763.
• Blue KC’s automated system, “Blue Touch,” will walk you through the process to
obtain eligibility and benefits information. You will need your Blue KC Provider
number, the member’s ID number, and date of birth. The phone number for Blue
Touch is 816-395-3929. Online eligibility and benefits information is available
at www.BlueKC.com. Click on the “Provider” icon.
• Blue KC may also be contacted at 816-395-2222.
Claims
• Blue KC will only accept claims via electronic billing. Use payer ID – 47171
• Blue KC Customer Service: 1-816-395-3678
• Lucet Customer Service: 1-800-528-5763
• All services must be billed in whole units. Partial units will not be paid.
Change in Demographics
• Please provide 45 days advance notice of any planned availability or
demographic changes when possible. Contractually, you must notify us within 72
hours of changes to address, phone number, fax number, or email.
• To submit changes, please complete the electronic update form appropriate for
your provider type, which is available on our website
at https://www.lucethealth.com/Providers. Select Blue KC under the ‘Choose
your health plan’ drop-down box, then click the Profile Updates box. If you have
questions, please get in touch with Provider Relations at 888-611-6285
or KCProviderRelations@lucethealth.com
Medical Records
• Medical records are to be provided upon request without charge.
Telehealth
• Reimbursement for telehealth services is subject to plan guidelines.
Blue Cross and Blue Shield of Michigan (BCBSM), including
United Auto Workers Retiree Medical Benefits Trust
(URMBT), General Motors (GM), and State of Michigan (SOM)
Provider Network through Blue Cross and Blue Shield of Michigan
Outpatient Authorizations
(Lucet)
No authorization is required. Outpatient services may be
reviewed retrospectively.
Authorization for
BCBSM Contracted
Facilities
(Lucet)
Please call 877-801-1159
or utilize WebPass
Benefits and Eligibility
(Lucet)
Please call 877-801-1159
or utilize WebPass
Claims Inquiries
(BCBSM)
See the Customer Service Phone number on the
Member’s ID card for claims or call 313-225-8100.
Provider Relations
(Lucet)
Please call 888-611-6285, submit a support case to
Login (lucethealth.com), or email
Providersupport@Lucethealth.com.
Deaf or Hard of Hearing
(Michigan Relay)
800-833-7833 (Voice)
800-833-5833 (TTY)
711 in your service area
Medical Necessity Appeal
(Lucet)
Please call 800-528-5763
or utilize WebPass
Authorizations
Outpatient Services
• BCBSM, URMBT, and GM: No authorization is required for outpatient services,
including psychological testing, ECT, 23-hour observation, and intensive
outpatient program (IOP) services for mental health and substance use disorders
(SUD). These services may be reviewed retrospectively.
• SOM: No authorization is required for outpatient services, including psychological
testing, ECT, 23-hour observation, and intensive outpatient services (IOP) for
mental health and SUD. These services may be reviewed retrospectively.
Intensive Outpatient
• BCBSM, URMBT, GM, and SOM: Lucet does not manage or authorize intensive
outpatient program (IOP) for mental health and substance use disorders
(SUD). Requests for IOP services should be sent directly to BCBSM for
processing.
• Out-of-network or non-participating providers and facilities
• BCBSM, URMBT, GM, and SOM: For “out-of-network” or “non-participating”
providers or facilities, Lucet does not authorize any level of care with the
exception of MESSA.
• MESSA: Callers to Lucet are referred to MESSA 800-336-0022 prompt six (6),
then prompt 1 for direction on authorization for admissions to non-participating
facilities
In-network services
• BCBSM, GM: Authorization is required for the following higher level of care
services for mental health and substance use disorders (SUD): inpatient
hospitalization, residential, and partial hospitalization. Contact Lucet for
authorization of these services.
• URMBT: Authorization is required for the following higher level of care services
for mental health and substance use disorders (SUD): inpatient hospitalization,
residential, and partial hospitalization. Contact Lucet for authorization of these
services. Pre-certification is required for all members for inpatient hospitalization.
• SOM: Lucet only authorizes in-network services, and authorization is required for
inpatient hospitalization, residential treatment (SUD only), partial hospitalization,
and intensive outpatient services.
Applied Behavior Analysis (ABA) Therapy
• BCBSM: ABA Therapy requires authorization for all visits. Call 877-563-
9347.
• GM: ABA Therapy requires authorization for all visits. Call 877-240-0705.
• SOM: ABA Therapy requires authorization for all visits. Call 866-503-
3158.
Transcranial Magnetic Stimulation
• BCBSM: Authorization is required for Transcranial Magnetic Stimulation
(TMS). For authorizations related to TMS, please refer to instructions on
the initial and continuation treatment request forms and see BCBSM’s
Medical Policy for this therapy.
• URMBT, GM, and SOM: Members have no TMS benefits.
Benefits
• BCBSM Commercial: If you have questions about member benefits, please
call BCBSM Customer Service at the phone number on the member’s
insurance ID card. Online eligibility and benefits information is available
at www.BCBSM.com.
• FEP: If you have questions about member benefits, please call 888-288-
2738.
• URMBT: If you have questions about member benefits, please call Lucet at
877-228-3912. For accumulator questions, please call BCBSM Customer
Service at the phone number found on the member’s insurance ID card.
• GM: If you have questions about member benefits, please call Lucet at 877-
240-0705.
• SOM: If you have questions about member benefits, please call BCBSM
Customer Service at 800-843-4876. Online eligibility and benefits information
is available at www.BCBSM.com.
Medical Necessity Appeals
Appeal Type
Timely Filing
Lucet Turn
Around Time
How to Submit a Request
Expedited
Appeal
180 days after
denial is
rendered
72 hours from
receipt of request
Phone: 833-964-6338
Standard
Appeal
180 days after
denial is
rendered
30 calendar days
from receipt of the
request
Online: WebPass
Phone: 800-248-2342
Fax: 816-237-2382
Mail: LUCET HEALTH
Attn: Appeals
PO Box 6729
Leawood, KS 66206-0729
* Member must currently be in treatment at the requested level of care, and urgency must be
demonstrated
Telehealth
• Reimbursement for behavioral health telehealth services is subject to plan
guidelines. Providers offering telehealth services should confirm with BCBSM
that the Member’s plan includes behavioral health telehealth benefits.
• Lucet does not authorize behavioral health telehealth services.
• Lucet will refer members to the BCBSM link (Ameriwell) to request telehealth
services: www.bcbsmonlinevisits.com. Members can also receive telehealth
services through BCBSM network providers offering telehealth services
Other information
Please visit http://www.bcbsm.com/providers/help/contact-us.html for all
other information.
Blue Cross Blue Shield of Louisiana (BCBSLA)
Authorizations
(BCBSLA)
Dial the customer service number on the back of the
member ID card and follow the IVR prompts.
BlueCard Eligibility
(BCBSLA)
Please call 1-800-676-2583
Benefits and Eligibility
(Lucet)
Please call 877-801-1159
or utilize WebPass
Claims Inquiries
(BCBSLA)
Use www.bcbsla.com/ilinkblue to check the status of
the claim. Or call 1-800-922-8866.
Provider Relations
(BCBSLA)
Please call 800-716-2299 or email
network.administration@bcbsla.com
Deaf or Hard of Hearing
(Michigan Relay)
800-833-7833 (Voice)
800-833-5833 (TTY)
711 in your service area
Medical Necessity Appeal
Expedited
(BCBSLA)
Please call 800-991-5638
Medical Necessity Appeal
(Lucet)
Please call 800-528-5763
or utilize WebPass
EDI Clearinghouse
(BCBSLA)
Please call 225-291-4334
or email EDICH@bcbsla.com
iLinkBLUE & EFT
(BCBSLA)
Please call 1-800-676-2583
Authorizations
• BCBSLA requires prior authorization for specific behavioral health services:
• Inpatient Hospital (including detox)
• Intensive Outpatient Program (IOP)
• Partial Hospitalization Program (PHP)
• Residential Treatment Center (RTC)
• Applied Behavior Analysis (ABA)
• Psychological and Neuropsychological Testing (PNT) for some ASO groups
• Outpatient ECT and Transcranial Magnetic Stimulation (TMS) for some ASO
groups
Medical Necessity Appeals
Appeal Type
Timely Filing
Lucet Turn
Around Time
How to Submit a Request
Expedited
Appeal
180 days after
denial is
rendered
72 hours from
receipt of request
Phone: 800-991-5638
Standard
Appeal
180 days after
denial is
rendered
30 calendar days
from receipt of the
request
Online: WebPass
Phone: 800-991-5638
Fax: 816-237-2382
Mail: LUCET HEALTH
Attn: Appeals
PO Box 6729
Leawood, KS 66206-0729
*Excludes Medicare and FEP plans
**Medical necessity appeal inquiries for Federal plans should be directed to BCBSLA at 800-991-5638.
*** Member must currently be in treatment at the requested level of care, and urgency must be
demonstrated
Claims Filing Requirements
Please include the following information on all BCBSLA claims:
• Member ID Number
• Patient Name and Date of Birth
• Date of Service
• Provider NPI
• Include all applicable procedure and diagnosis codes (it is important to file “ALL”
applicable diagnosis codes to the highest degree of specificity)
Timely Claims Filing
• BCBSLA claims must be filed within 15 months of the date of service or the
length of time stated in the member’s contract, if different. Claims received after
15 months, or the length stated in the member’s contract, will be denied, and the
member and Blue Cross should be held harmless for these amounts.
• BCBSLA claims for FEP members must be filed by December 31 of the year
after the service was rendered.
• Self-insured plans and plans from states other than Louisiana may have different
timely filing guidelines. Please call the Customer Care Center at 1-800-922-8866
to determine what the claims filing limits are for your patients.
• BCBSLA claims for OGB (Office of Group Benefits) members must be filed
within 12 months of the date of service. Claims received after 12 months will be
denied for timely filing, and the OGB member and Blue Cross should be held
harmless. Claims reviews, including refunds and recoupments, must be
requested within 18 months of the receipt date of the original claim. OGB claims
are not subject to late payment interest penalties.
Claims Submission
Electronic Claims:
Electronic Claims – Providers filing electronic claims should use payer ID –
23738 (Professional/HCFA) U3738 (Institutional/UB)
Paper Claims - BCBSLA paper claims should be mailed to:
Blue Cross and Blue Shield of Louisiana
P.O. Box 98029
Baton Rouge, LA 70898
FEP paper claims should be mailed to:
P.O. Box 98028
Baton Rouge, LA 70898-9028
Change in Demographics
• To update your address or contact information, complete BCBSLA’s online
interactive Provider Update Form
Medical Records
• Medical records are to be provided upon request without charge, as agreed to in
your BCBSLA provider contract.
Telehealth
• Reimbursement for telehealth services is subject to plan guidelines.
SCAN
Precertification
(Lucet)
Please call 877-267-7555
or utilize WebPass
Benefits and Eligibility
(Lucet)
Please call 877-267-7555
or utilize WebPass
Provider Relations
(Lucet)
Please call 888-611-6285, submit a support
case to log in or email
Providersupport@Lucethealth.com.
Medical Necessity Appeals
(SCAN)
To initiate an appeal, you will need to contact the
appropriate SCAN number:
Members – 855-844-7226
Providers – 877-778-7226
Claims Inquiries
(Lucet)
Please call 877-267-7555or utilize WebPass
Deaf or Hard of Hearing
(Relay)
Dial 711 to identify the correct toll-free number for
your location.
Prescription Questions
(SCAN)
Please call 855-844-7226
Medical Case Management
(SCAN)
Please call 855-844-7226
Behavioral Health Case
Management Fees
None
ID Card
(SCAN)
Please call 855-844-7226
Pharmacy Vendor
(SCAN)
Please call 855-844-7226
Telehealth Provider
(Lucet)
Please call 888-611-6285, submit a support
case to log in or email
Providersupport@Lucethealth.com.
Telehealth Members
(SCAN)
If a member has questions about urgent medical
needs, please refer to SCAN’s telehealth provider at
the following website:
www.doctorsondemand.com/scan
Specialty Benefit Template:
RX program
(SCAN)
Please call 855-844-7226
Transportation Benefit
(SafeRide)
Please call 844-714-2218. Please see below for
additional details.
Managed Plans
1. SCAN Balance HMO
2. SCAN Classic HMO
3. SCAN Heart Health HMO
4. SCAN Venture HMO
Authorizations
Prior authorization is never required for Emergency Services, including behavioral
health services necessary to screen and stabilize Members. Prior authorization is
always required for planned out-of-area services that are not Urgent or Emergent.
Prescription Questions
• For prescriptions, if they ask about a refill or change/adjustment to a prescription
ordered by your providers, please refer to your internal processes to assist them.
• For questions about coverage, costs, or prior authorization, advise the caller that
SCAN Member Services can assist and refer to the toll-free number in the chart
• For prior authorizations, the member may seek assistance or status from the
provider to support a request already under review. Please confirm with the caller
if a prior authorization was submitted and what support is needed to determine if
the call should be directed to Member Services or the provider.
• Refer to Member Services to submit a new prior authorization, check the status
of an existing one, or dispute a decision.
Services
Non-Covered Services
• Medical Marijuana
• ABA
• IOP
• Residential Substance Abuse Treatment
• Sub-Acute Detox for Substance
• Halfway House
Non-covered Providers
• Licensed Mental Health Counselor (LMHC)
• Board Certified Behavioral Analyst (BCBA)
Claims
• Claims must be filed within 365 days from the date of service to meet timely filing
requirements.
• Clean claims will be processed within 30-60 days. To check the status of a claim,
please check Availity
FYI: We will process most claims within ten (10) days, but the CMS requirement is to
pay contracted providers within 60 days and non-contracted providers within 30 days.
• Paper Claims:
Claims Address:
• PO Box 21487
Eagan, MN 55121
• Electronic Claims submission:
Clearinghouse:
• TTPS (Trizetto Trading Partner Solutions)
• Payer ID – NDX99
• All services must be billed in whole u0nits. Partial units will not be paid.
• All higher levels of care must be billed based on the number of days authorized for
proper benefit and claim adjudication.
Appeals
Lucet will not handle appeals for SCAN. Any caller inquiring about or wanting to initiate
an appeal will need to contact the appropriate SCAN number:
Members – 855-844-7226
Providers – 877-778-7226
Benefits
Benefits vary by group and plan. For Behavioral Health and Substance use benefit
validation, providers are encouraged to contact the Lucet Contact Center at 866-730-
5006.
Transportation Benefit
Scan members have covered transportation benefits—warm transfer members to Safe
Ride: 1-844-714-2218. SafeRide has an interpreter line for bilingual callers.
Lucet will not coordinate the transportation. SafeRide will. Lucet will transfer the call to
SCAN’s transportation line, which their transportation vendor, SafeRide, answers.
SCAN has provided additional information below so we can speak to the Transportation
benefit if asked.
Transportation Benefits:
•For Classic HMO, it’s 54 one-way trips
•For Balance HMO-SNP, it’s 54 one-way trips, of which 28 can be non-medical
•For Heart First HMO-SNP, it’s 54 one-way trips, of which 28 can be non-medical
•For Venture HMO, it’s eight (8) one-way trips
Members can schedule weekly rides for mental health appointments. SafeRide can
schedule these rides! The member would call SafeRide to schedule those rides.
List of what information the member needs to have ready to request/schedule a ride:
•Date of appointment.
•Appointment time.
•Pick up location.
•Drop-off location.
•What type of appointment are they going to.
•Doctor’s phone number.
They will also need to verify HIPAA.
Change in Demographics
Please provide 45 days advance notice of any planned availability or demographic
changes when possible. Contractually, you must notify us within 72 hours of changes
to your address, phone number, fax number, or email.
To submit changes, please complete the electronic update form appropriate for your
provider type, available on our website at https://www.lucethealth.com/Providers.
Select SCAN under the ‘Choose your health plan’ drop-down box, then click the
Profile Updates box. If you have questions, please contact Provider Relations at 888-
611-6285 or Provider relations@lucethealth.com.
Medical Records
Medical records requested by Lucet, SCAN, or a regulatory entity such as HHS are to
be provided within a reasonable timeframe and free of charge.
Members may request a copy of their New Directions medical record by submitting a
written request to Compliance@lucethealth.com.
Appendix A: Blue Plan Groups
Note: Information in the appendix is specific to each plan (i.e., not a Lucet process). It
may be subject to change. If you have questions, please direct them to the applicable
plan.
Appendix A.1: Tampa General Hospital
Customer Service
Please call 1-844-594-6012
PPO Provider Locator Please call 1-800-810-2583
Preadmission Certification
Please call 1-855-288-8357
Provider Benefits/Eligibility
Please call 1-855-630-6825
Pharmacist Help Line
Please call 1-800-545-8349
EAP
Please call 1-800-624-5544
Timely Filing
• Timely filing of claims is 180 days.
Claims
• Providers file claims and direct questions about claim payments to the local Blue
Cross and/or Blue Shield Plan.
• Claims submitted electronically using payer ID– 00590.
• Members file claims to:
Birmingham Service Center
PO Box 10527
Birmingham, AL 35202-0500
Appendix A.2: Polk County Public Schools
Customer Service
Please call 1-855-630-6824
PPO Provider Locator Please call 1-800-810-2583
Preadmission Certification
Please call 1-855-288-8357
Provider Benefits/Eligibility
Please call 1-855-630-6825
Pharmacist Help Line
Please call 1-800-545-8349
EAP
Please call 1-800-272-7252
PCSB Employee Clinic
(Contracts separately
with group)
Please call 1-863-419-3322
Timely Filing
• Timely filing of claims is 180 days.
Claims
• Providers file claims and direct questions about claim payments to the local Blue
Cross and/or Blue Shield Plan.
• Claims submitted electronically using payer ID– 00590.
• Members file claims to:
Birmingham Service Center
PO Box 10527
Birmingham, AL 35202-0500
Appendix B: Medicare Advantage Plans contracted with
Lucet
Note: Information in the appendix is specific to each plan (i.e., not a Lucet process). It
may be subject to change. If you have questions, please direct them to the applicable
plan.
Appendix B.1: BayCare Select Health Plan
Benefits & Eligibility
(BayCare Select Health Plan)
See the Customer Service Phone number on
the Member’s ID card for benefits/eligibility or
call 866-509-5396
Provider Relations/ Operations
(BayCare Select Health Plan)
866-509-5396
Claims Inquiries
(BayCare Select Health Plan)
866-509-5396
Deaf or Hard of Hearing
(Relay)
Relay services
Dial 711 for the state relay service toll-free
number.
Provider Appeals
(BayCare Select Health Plan)
www.baycareplus.org
appeals@baycarehealthplans.org
866-509-5396
DNIS 3827
Timely Filing
• BayCare Select Health Plan claims must be filed according to your contract:
o Twelve (12) months from the date of service or date of discharge; or
o Six (6) months from the date of service; or
o 90 days from the date of discharge
• Non-contracted providers must file within twelve (12) months from the date of
service or date of discharge.
• Claims received after twelve (12) months from the date of service or date of
discharge or after the length of time stated in the member’s contract will be
denied. In such an event, the member and BayCare Health Plan will be held
harmless for these amounts.
Claims Submission
Electronic Claims:
• Providers filing electronic claims should use payer ID – 81079.
Telehealth
• Reimbursement for telehealth services is subject to plan guidelines.
• Important notice: Telehealth services are not a covered benefit for BayCare
Select Health Plan
Appendix B.2: Mutual of Omaha Medicare Advantage
Company
Benefits & Eligibility
See the Customer Service Phone number on
the Member’s ID card for benefits/eligibility or
call.
Cincinnati, OH (KY) – 1-877-603-0785
San Antonio, TX – 1-866-488-0249
Provider Relations/ Operations
Cincinnati, OH (KY) – 1-877-603-0785
San Antonio, TX – 1-866-488-0249
Claims Inquiries
Cincinnati, OH (KY) – 1-877-603-0785
San Antonio, TX – 1-866-488-0249
Deaf or Hard of Hearing
(Relay)
Relay services
Dial 711 for the state relay service toll-free
number.
Provider Appeals
www.mutualofomahacareadvantage.com
appeals@mutualmedicareadvantage.com
Cincinnati, OH (KY) - 877-603-0785
DNIS 3802
San Antonio, TX - 866-488-0249
DNIS 4859
Timely Filing
• Mutual of Omaha Medicare Advantage Company claims must be filed within 180
days from the date of service or date of discharge.
• Claims received after 180 days, or the length of time stated in the member’s
contract, will be denied. In such an event, the member and Mutual of Omaha
Medicare Advantage Company will be held harmless for these amounts.
Claims Submission
Electronic Claims:
• Providers filing electronic claims should use payer ID – 82275.
Telehealth
• Reimbursement for telehealth services is subject to plan guidelines.
• Important notice: Telehealth services are not a covered benefit for Mutual of
Omaha Medicare Advantage Company.
Appendix B.3: Medicare Advantage Insurance Company of
Omaha
Benefits & Eligibility
See the Customer Service Phone number on
the Member’s ID card for benefits/eligibility or
call.
Dallas, TX – 1-844-335-3776
El Paso, TX – 1-844-335-2918
Denver, CO – 1-844-335-4178
Provider Relations / Operations
Dallas, TX – 1-844-335-3776
El Paso, TX – 1-844-335-2918
Denver, CO – 1-844-335-4178
Claims Inquiries
Dallas, TX – 1-844-335-3776
El Paso, TX – 1-844-335-2918
Denver, CO – 1-844-335-4178
Deaf or Hard of Hearing
Relay services
Dial 711 for the state relay service toll-free
number
Provider Appeals
Dallas, TX – 1-844-335-3776
El Paso, TX – 1-844-335-2918
Denver, CO – 1-844-335-4178
Timely Filing
• Medicare Advantage Insurance Company of Omaha claims must be filed within
180 days from the date of service or date of discharge.
• Claims received after 180 days, or the length of time stated in the member’s
contract, will be denied. In such an event, the member and Medicare Advantage
Insurance Company of Omaha will be held harmless for these amounts.
Claims Submission
Electronic Claims:
• Providers filing electronic claims should use payer ID – 82275.
Telehealth
• Reimbursement for telehealth services is subject to plan guidelines.
• Important notice: Telehealth services are not a covered benefit for Medicare
Advantage Insurance Company of Omaha.
Appendix B.4: Physicians Health Plan (PHP) Medicare
Benefits & Eligibility
See the Customer Service Phone number on
the Member’s ID card for benefits/eligibility or
call
PHP Sparrow & Sparrow Advantage:
1-844-529-3757
PHP Covenant & Covenant Advantage: 1-844-
329-9247
PHP Advantage: 1-855-229-2172
Provider Relations / Operations
PHP Sparrow & Sparrow Advantage:
1-844-529-3757
PHP Covenant & Covenant Advantage: 1-844-
329-9247
PHP Advantage: 1-855-229-2172
Claims Inquiries
PHP Sparrow & Sparrow Advantage:
1-844-529-3757
PHP Covenant & Covenant Advantage: 1-844-
329-9247
PHP Advantage: 1-855-229-2172
Deaf or Hard of Hearing
Relay services
Dial 711 for the state relay service toll-free
number
Provider Appeals
PHP Sparrow & Sparrow Advantage:
1-844-529-3757
PHP Covenant & Covenant Advantage: 1-844-
329-9247
PHP Advantage: 1-855-229-2172
Timely Filing
• Physician Health Plan (PHP) Medicare claims must be filed within 180 days from
the date of service or date of discharge.
• Claims received after 180 days, or the length of time stated in the member’s
contract, will be denied. In such an event, the member and Physician Health Plan
(PHP) Medicare will be held harmless for these amounts.
Claims Submission
Electronic Claims:
• Providers filing electronic claims should use payer ID – 83276.
Telehealth
• Reimbursement for telehealth services is subject to plan guidelines.
• Important notice: Medicare for Physician Health Plan (PHP) does not cover
Telehealth services.
Appendix B.5: Mary Washington Health Plan
Benefits & Eligibility
See the Customer Service Phone number on
the Member’s ID card for benefits/eligibility or
call.
Mary Washington: 1-844-529-3760
Provider Relations / Operations
Mary Washington: 1-844-529-3760
Claims Inquiries
Mary Washington: 1-844-529-3760
Deaf or Hard of Hearing
Relay services
Dial 711 for the state relay service toll-free
number
Provider Appeals Mary Washington: 1-844-529-3760
Timely Filing
• Mary Washington Health Plan claims must be filed within 180 days from the date
of service or discharge.
• Claims received after 180 days, or the length of time stated in the member’s
contract, will be denied. The member and Mary Washington Health Plan will be
held harmless for these amounts in such an event.
Claims Submission
Electronic Claims:
• Providers filing electronic claims should use payer ID – 83269.
Telehealth
• Reimbursement for telehealth services is subject to plan guidelines.
• Important notice: Telehealth services are not a covered benefit of the Mary
Washington Health Plan
