- Behavioral Health
- Commercial Plans
- Tufts Health Public Plans
Coverage is provided for benefits related to children and adolescents up to age 19 with behavioral health disorders that substantially interfere with or substantially limit their functioning and social interactions.
Medical Necessity Guidelines
- In-Home Behavioral Services (IHBS): Massachusetts Products
- In-Home Therapy Services (IHTS): Massachusetts Products
- Mobile Crisis Intervention (MCI): Massachusetts Products
- Targeted Case Management Services: Intensive Care Coordination (ICC): Massachusetts Products
- Behavioral Health Level of Care Determinations
Behavioral Health Child and Adolescent (BHCA) services are considered to be the diagnosis and treatment of child-adolescent mental health disorders which substantially interfere with or substantially limit the functioning and social interactions of the child or adolescent; provided, that said interference or limitation is documented by, and the referral for said diagnosis and treatment is made by, the child's primary care provider, primary pediatrician, or a licensed mental health professional, or is evidenced by conduct, including, but not limited to:
- An inability to attend school as a result of such a disorder,
- The need to hospitalize the child or adolescent as a result of the disorder, or
- A pattern of conduct or behavior caused by such a disorder which poses a serious danger to self or others.
These BHCA services shall take place in the least restrictive clinically appropriate setting and shall consist of a range of intermediate and outpatient services that shall permit medically necessary, active care expected to lead to improvement of the condition in a reasonable period of time, as well as medically necessary noncustodial treatment for the behavioral health disorders. The covered services may be provided to the child, the child's parent(s), and/or other appropriate caregivers.
In-Home Behavioral Services (IHBS)
A combination of medically necessary behavior management therapy and behavior management monitoring; provided, however, that such services shall be available, when indicated, where the child resides, including in the child's home, a foster home, a therapeutic foster home, or another community setting. In-home behavioral services include:
- Behavior management monitoring: monitoring of a child's behavior, the implementation of a behavior plan and reinforcing implementation of a behavior plan by the child's parent or other caregiver.
- Behavior management therapy: therapy that addresses challenging behaviors that interfere with a child's successful functioning; provided, however, that "behavior management therapy" shall include a functional behavioral assessment and observation of the youth in the home and/or community setting, development of a behavior plan, and supervision and coordination of interventions to address specific behavioral objectives or performance, including the development of a crisis-response strategy; and provided further, that "behavior management therapy" may include short-term counseling and assistance. This service is usually provided by a staff team including a behavior management therapist and a behavior management monitor.
The minimum staff qualifications for each are as follows:
Behavior Management Therapist:
- Master’s level practitioner (a master’s level practitioner for these purposes includes persons with the following credentials: Developmental-behavioral pediatricians, developmental-behavioral pediatric fellows, LICSWs, LCSWs, LMFTs, LMHCs, licensed psychologists, master’s-level counselors, marriage and family therapy interns, mental health counselor interns, psychiatric nurse mental health clinical specialists, psychiatric nurse mental health clinical specialist trainee, psychiatric nurses, psychiatrists, psychiatry residents, psychology interns, and social work interns. Note that all unlicensed master’s-level counselors and/or interns must provide services under the direct supervision of a LICSW, LMFT, LMHC, LCSW, LADC I, Psychologist, Psychiatric Nurse, or Nurse Clinical Specialist consistent with applicable state licensure requirements. Please see Massachusetts State Plan 08-004 for further definition of the credentials described above); and
- Board-Certified Behavior Analyst (BCBA); or
- Enrolled in a behavior analyst training program and eligible for certification within nine months; or
- A psychologist licensed by the Massachusetts Board of Registration in Psychology with experience performing functional behavioral assessments and implementing and evaluating intervention strategies; or
- A masters-level mental health practitioner working under the supervision of a BCBA; or a masters-level mental health practitioner with relevant training and two years of experience inclusive of but not limited to:
- Conducting functional behavioral assessments (FBA) of youth with serious emotional and behavioral disturbances that include observing and analyzing behavior in settings where the behavior is naturally occurring; evaluating specific antecedent stimuli and consequences; and understanding the values, skills, and resources of those who are responsible for implementing the behavior plan; and
- Selecting interventions and strategies based on the results of the FBA and designing behavior plans that include intensive behaviorally oriented interventions; and
- Evaluating progress based on both qualitative and quantitative data and making adjustments to the behavior plan as needed; and
- Working with parents/caregivers and paraprofessional staff in homes and other community-based settings to implement behavior plans using techniques grounded in principles of positive behavior support(PBS) and/or applied behavioral analysis (ABA) with an aim toward extinguishing a wide range of challenging behaviors and increasing more socially acceptable behaviors that are age or developmentally appropriate.
- Supervision by a clinician meeting one of the above criteria; and
- A bachelor’s degree in a human services field from an accredited university and one year of direct relevant experience working with youth and families who require behavior management to address behavioral health needs; or
- An associate’s degree and a minimum of two years of relevant direct service experience working with youth and families who require behavior management to address behavioral health needs.
In-Home Therapy (IHT)Medically necessary therapeutic clinical intervention or ongoing training, as well as therapeutic support; provided however, that the intervention or support shall be provided where the child resides, including in the child's home, a foster home, a therapeutic foster home, or another community setting.
Therapeutic clinical intervention: intervention that shall include:
- a structured and consistent therapeutic relationship between a licensed clinician and a child and the child's family to treat the child's mental health needs, including improvement of the family's ability to provide effective support for the child and promotion of healthy functioning of the child within the family; and
- the development of a treatment plan; and
- the use of established psychotherapeutic techniques, working with the family or a subset of the family to enhance problem solving, limit setting, communication, emotional support or other family or individual functions.
Ongoing therapeutic training and support: services that support implementation of a treatment plan pursuant to therapeutic clinical intervention that shall include, but not be limited to, teaching the child to understand, direct, interpret, manage and control feelings and emotional responses to situations and assisting the family in supporting the child and addressing the child's emotional and behavioral health needs.
- The IHT team employs a multidisciplinary model, with both professional and paraprofessional staff
- The professional staff has a degree from the MassHealth-approved list and is trained in working with youth and their families, including training in family therapy
- Paraprofessional staff has a degree from the MassHealth-approved list and is trained to provide family members with therapeutic support for behavioral health needs
- The IHT program has a program director who is an independently licensed clinician
- The IHT provider ensures that an independently licensed senior clinician provides weekly supervision to professional staff
- The IHT provider ensures that a licensed behavioral health clinician provides weekly supervision to paraprofessional staff
- The IHT team will have access to psychiatric expertise for consultation as needed. The team includes a board-certified or board-eligible child/adolescent psychiatrist (ABPN) or a certified or certification-eligible child/adolescent/family-trained behavioral health psychiatric nurse clinical specialist (ANCC), who is available during normal business hours for consultation related to treatment planning, medication concerns, and crisis intervention on an as-needed basis. The psychiatric clinician is available for provider consultation within one hour.
- A senior-level, independently licensed clinician trained in working with youth is available to the staff and the supervisor 24 hours a day, seven days a week for consultation on an as-needed basis
Mobile crisis intervention (MCI)A short-term, mobile, on-site, face-to-face therapeutic response service that is available 24 hours a day, 7 days a week to a child experiencing a behavioral health crisis. MCI is used to identify, assess, treat and stabilize a situation, to reduce the immediate risk of danger to the child or others, and to make referrals and linkages to all medically necessary behavioral health services and supports and the appropriate level of care. The intervention shall be consistent with the child's risk management or safety plan, if any. MCI includes a crisis assessment and crisis planning, which may result in the development or update of a crisis safety plan.
- MCI utilizes a multidisciplinary model with both professional and paraprofessional staff and maintains staffing levels as warranted by data trends.
- MCI is staffed with master’s level clinicians trained in working with youth and families, with experience and/or training in non-violent crisis intervention, crisis theory/crisis intervention, solution-focused intervention, motivational interviewing, behavior management, conflict resolution, family systems, and de-escalation techniques.
- MCI is also staffed with bachelor’s level or paraprofessional staff experienced or trained in providing ongoing in-home crisis stabilization services and in navigating the behavioral health crisis response system that support brief interventions that address behavior and safety.
- A board-certified or board-eligible child psychiatrist or child trained psychiatric nurse behavioral health clinical specialist is available for phone consultation to MCI 24-hours a day and must respond within 15 minutes of a request from MCI staff and is available for face-to-fact appointments with the youth for urgent medication management evaluations or urgent medication management appointments within 48 hours of a request if the youth has no existing provider
Intensive Care Coordination (ICC)
A collaborative service that provides targeted case management services to children and adolescents with a serious emotional disturbance, including individuals with co-occurring conditions, in order to meet the comprehensive medical, behavioral health, and psychosocial needs of an individual and the individual's family, while promoting quality, cost effective outcomes.
- ICC includes an assessment, the development of an individualized care plan, referrals to appropriate levels of care, monitoring of goals, and coordinating with other services and social supports and with state agencies, as indicated.
- The service shall be based upon a system of care philosophy and the individualized care plan shall be tailored to meet the needs of the individual.
- ICC shall include both face-to-face and telephonic meetings, as indicated and as clinically appropriate.
- ICC is delivered in office, home or other settings, as clinically appropriate.
The ICC provider ensures adequate staffing of care coordinators with master’s degree in a behavioral health field (including, but not restricted to, counseling, family therapy, social work, psychology, etc.) from an accredited college or university and of care coordinators with bachelor’s degree in a human services field from an accredited academic institution and one year of relevant experience working with families or youth, if the bachelor’s degree is not in a human services field, additional life or work experience may be considered in place of the human services degree, or care coordinators with an associate’s degree or high school diploma and a minimum of five years of experience working with the target population; experience in navigating any of the child/family-serving systems; and experience advocating for family members who are involved with behavioral health systems.
The following are not considered to be child-adolescent mental health intermediate care and outpatient services and are not required to be covered by an insured health plan:
- Programs in which the member has a pre-defined duration of care without the health plan's ability to conduct concurrent determinations of continued medical necessity for an individual.
- Programs that only provide meetings or activities that are not based on individualized treatment planning.
- Programs that focus solely on improvement in interpersonal or other skills rather, than services directed toward symptom reduction and functional recovery related to specific mental health disorders.
- Tuition-based programs that offer educational, vocational, recreational, or personal development activities, such as a therapeutic school, camp, or wilderness program. The health plan must provide coverage for medically necessary services provided while the individual is in the program, subject to the terms of the member's evidence of coverage including any network requirements or co-payments/coinsurance provisions.
- Programs that provide primarily custodial care services
Who submits the notifications?
It is the treating provider’s responsibility to submit the notification for outpatient behavioral health and substance use disorder services.
Providers must provide an initial notification for patients who are new to the practice. If the patient is not new but the previous notification is more than 12 months old and has therefore expired, providers must submit a new notification. Upon submission of the initial notification, 8 visits will be available.
Notifications for Additional Visits
Providers must submit a notification for patients who are continuing with their treatment and have exhausted all visits within the 12 month date range.The member may also submit a subsequent request. This notification will grant another 8 visits.
Submitting Notifications for Initial and Additional Visits
Providers can submit notifications for both initial and additional visits by:
- Logging in to the secure provider website to submit a notification. Refer to the Behavioral Health Self Service User Guide for assistance with submitting notifications.
- Using the interactive voice response (IVR) system by calling 800.208.9565.
Note: Notifications can be backdated up to 30 calendar days.
Providers will receive a new certification number each time a notification is submitted. The initial letter of the notification number indicates the process by which it was submitted:
- Online: Begins with K
- IVR: Begins with V
- Behavioral Health Coordinator via phone: Begins with R
How long are notifications good for?
Notifications are valid for 12 months from the start date or until the number of visits on the notification are exhausted. This means that visits received as a result of notification “carry over” into a new calendar or plan year. Notifications do not override the member’s benefit limit.
Notifications and Mental Health Parity
Notifications must be obtained for members covered under Mental Health Parity laws. Outpatient behavioral health services must be medically necessary. View the Outpatient Psychotherapy Medical Necessity Guidelines.
- Designated Facilities Information
- Instructions for Reporting a Discharge
- Transition to Home Referral Request Information
- MA Substance Use Disorder Mandate - FAQs for DF Providers
- MA Substance Use Disorder Mandate - FAQs for FFS Facilities
- 7 Day Treatment Update Form
- Admissions/Discharge Notification Form for Non-DFs
- Autism, ABA and Habilitative Therapy Medical Necessity Guidelines
- Autism Professional Payment Policy
- ABA Initial Services Request—Assessment and Treatment Planning (H0031) only
- ABA Autism Service Request (Initial and Continued)
- Early Intervention ABA Service Request (H2019 only)
- Payment Policies
- Mental Health Self Service User Guide
- Provider Manuals
- Provider Education
- Mental Health Provider Credentialing Forms
Designated Facilities Manual: Developed by the Behavioral Health Department to supply designated facilities and staff with details on the designated facility operating guidelines of Tufts Health Plan.