QUEST Integration – Behavioral Health Assistance, Standard Care

Original Effective Date:

08/01/1994

Current Effective Date:

04/01/2015

HMSA’s QUEST Integration plan partners with Carelon Behavioral Health^SM to assist members in need of behavioral health intervention and triage, and assist members in finding an appropriate behavioral health care provider as needed. QUEST Integration adult members age 18 years and older who are in need of intensive behavioral health services due to serious and persistent mental illness (SPMI) are to be referred to the Community Care Services (CCS) program. Members under age 18 years of age who are diagnosed with severe emotional behavior disorders are to be referred to the Department of Health, Child and Adolescent Mental Health Division (CAMHD) Support for Emotional and Behavioral Development (SEBD) program.

Assistance for standard behavioral health may include:

• Linking the member to resources and services.
• Educating the member, family, and other sources of support.
• Maintaining interaction with providers.
• Coordinating and assessing care by monitoring patient registration.
• Assisting with benefit flexing.
• Advocating for the member’s needs.

Benefit Limit

The cost of detoxification services and educational programs to which drinking or drugged drivers are solely referred by the judicial system, or services performed by mutual self-help groups, are not eligible for benefits.

Precertification

The QUEST Integration plan requires precertification in specified situations (see Precertification). Payment for services will not be made unless precertification is obtained through HMSA’s Behavioral Health Services QUEST Integration (Carelon Behavioral Health) for the following services:

• All services rendered by providers outside the QUEST Integration network (non-participating).
• All services provided out of state.

Non-medical services such as interisland travel, lodging, and language translation provided in connection with behavioral health care must be authorized by calling QUEST Integration Provider Services.

Confidentiality and Security

Patient information is maintained with the utmost confidentiality and security in accordance with the stringent guidelines established under the federal Health Insurance Portability and Accountability Act. Information is used only to identify patients as is appropriate to analyze community standards of care to establish best practices.

Carelon Behavioral HealthSM is an independent company providing behavioral health utilization management and quality improvement services on behalf of HMSA.

Revision History