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Medica Administrative Manual  >  Network Operation and Support Services > Mental Health/Substance Use Disorder Services

Mental Health/Substance Use Disorder Services

Medica Behavioral Health (MBH) provides and coordinates mental health/substance use disorder (MH/SUD) services. MBH, administered by Optum, contracts with a network of behavioral health clinicians, programs and facilities to serve the behavioral health needs of most Medica members. Special rules apply for members of Mayo Medical Plan, City of Rochester, Olmsted County and Black River (contact Provider Services for information regarding these members). 

This section includes detailed information on:

Overview of Services

Medica's goal is to offer Medica members the most effective behavioral health treatment in the least restrictive setting.

Medica Behavioral Health is a full-service Care Advocacy Center with independently licensed mental health professionals who can assist providers and members with the following: 

  • Assess and triage behavioral health crisis situations. 
  • Assist with urgent appointment needs including accessing reserved appointments for members discharging from inpatient who are in need of a 7-day follow-up appointment with a behavioral health professional. 
  • Assistance with out-of-network claims submission.
  • Benefit education.
  • Answer claims questions.
  • Assistance in identification of and access to outpatient care, including open certification to access the MBH network of outpatient clinicians.
  • Authorization for more intensive outpatient services provides opportunity to evaluate complexity of clinical presentation and opportunity to apply additional resources. 
  • Coordination of inpatient and residential services to ensure appropriate level of care and to facilitate outpatient step down and follow up care.
  • Transition of Care support to promote successful transition to the community post-hospitalization and reduce risk of re-hospitalization.
  • Refer a member to behavioral health case management.
  • Live and Work Well — Prevention, self-assessment, education, self-management tools.
  • Sanvello – wellness app that builds resilience through cognitive behavioral skill building.
  • Providers and members may call 1 (800) 848-8327 and follow the prompts. 

Medica members have the highest level of benefit for MH/SUD services when they use the Medica Behavioral Health provider network. Medica Behavioral Health representatives are available to assist in locating network providers. In addition, lists of network providers are available through:

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Emergency Care

Twenty-four hour emergency care is available from the MBH network. Medica Behavioral Health staff are available 24/7. Calls are assessed for urgency, and appropriate arrangements are made for face-to-face or virtual services as indicated by the situation and member preference.

For Benefit Information

Most Medica members have outpatient and inpatient mental health/substance use disorder benefits, which vary according to the member's benefit document. To obtain benefit information, members and participating providers may call Medica Behavioral Health where representatives are available to assist members and providers with general information, questions about behavioral health services, benefit interpretation, and resolution of problems and complaints.

Medica Behavioral Health contact numbers:

  • For emergency care assistance or benefit information, call 1 (800) 848-8327 and follow the prompts to connect to the department most specific to your query.
  • For claims information, call 1 (866) 214-6829 and follow the prompts.

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Participating Providers

Medica Behavioral Health contracts with psychiatrists, licensed psychologists, licensed therapists and counselors, clinical nurse specialists, substance use disorder programs, residential and acute care mental health and substance use disorder facilities.

Medica Behavioral Health has a large network of traditional and virtual providers in the Medica Service Area where members can obtain MH/SUD services. To locate a network provider:

Most outpatient services do not require prior authorization. Prior authorization may be needed for other, more intensive, behavioral health care. To determine if prior authorization is needed or to obtain prior authorization, visit the Provider Express portal at Optum - Provider Express Home or call Medica Behavioral Health. Generally, the provider gives Medica Behavioral Health clinical information in order to obtain authorization.

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Types of Services

Behavioral health services furnished by participating providers begin with an assessment by a mental health clinician. A treatment plan is developed through the assessment process. Ongoing therapy may be provided by the assessor, but in some cases, a referral may be made to a mental health clinician with expertise in a special area of treatment.

Behavioral health services include but are not limited to:

  • Individual, family and group therapy.
  • Diagnostic assessment.
  • Individual treatment planning.
  • Psychiatric evaluation and medication management.
  • Hospitalization when medically necessary.

Substance use disorder services furnished by participating providers include but are not limited to:

  • Diagnostic assessment.
  • Individual treatment planning.
  • Outpatient and residential substance use disorder programs.

Medical Behavioral Health member services can assist members and providers looking for referrals to providers that have specialty areas of practice including cultural competency, multi-lingual, substance use disorder care, eating disorder care, child and adolescent specialties including autism spectrum disorder, or competencies in a particular diagnosis.  The Live and Work Well website also has a provider search filter that can assist with identifying providers to meet the specific needs of members.

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Requesting Services

To obtain MH/SUD services, a member may identify a network clinician online (using Medica’s provider-search tool) or at the Live and Work Well website (using guest code MEDICA to log in). For an initial assessment to determine behavioral health needs and for routine mental health care, (outpatient mental health individual, group or family therapy) the member can schedule directly with a network clinician. As mentioned above, a member may also choose to call Medica Behavioral Health for assistance in finding a network clinician that is a good fit for them or understanding their benefits.

For substance use disorder program services and more intensive services such as mental health day treatment, prior authorization may be required. The member or provider contacts Medica Behavioral Health to obtain prior authorization.

Medica Behavioral Health expects that members will be able to access behavioral health services within the following timelines:

  • Emergency services are available immediately
  • Urgent services are available within 48 hours
  • Routine services are typically available within 10 business days

For emergency or urgent behavioral health needs, or if you are seeking routine services and are having difficulty scheduling with a provider, call the Medica Behavioral Health Intake Number at 1 (800) 848-8327.

Inpatient Services

Inpatient psychiatric consultations for members in a medical/surgical bed may be provided by network psychiatrists without prior authorization.

Inpatient Admissions

To access in-network benefits for inpatient behavioral health admissions, no prior authorization is required but we do ask that hospitals notify us upon the admission of one of our members.

Out-of-network benefit admissions typically require authorization, depending on the certificate of coverage. Information on benefit levels and authorization requirements can be obtained by calling Medica Behavioral Health at 1 (800) 848-8327 and following the prompts.

Emergency Admissions

 

Medica Behavioral Health considers an admission to an inpatient psychiatric hospital as an event that is typically the result of an emergency.  We ask that that hospitals notify us upon the admission of one of our members as soon as it is reasonably possible after the confinement begins by calling 1 (800) 848-8327.

 

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Substance Use Disorder Information Disclosure Requirements

Substance use disorder (SUD) information is protected under federal law and regulation.  Federal regulation permits the sharing of SUD information with contracted providers for a number of permissible purposes including, in part, care coordination and case management in support of payment or health care operations.  Contracted providers of Medica may receive from Medica or its contracted designee SUD information requiring protection under 42 CFR Part 2. To the extent a contracted provider receives SUD information under the federal regulation, the provider:

  • Is fully bound by the provisions of 42 CFR Part 2 upon receipt of the patient identifying SUD information, and must implement appropriate safeguards to prevent unauthorized uses and disclosures; 
  • Must report any unauthorized uses, disclosures, or breaches of patient identifying information to Medica; and
  • Must not re-disclose the information to a third party unless the third party is a contract agent of the contracted provider helping to provide services described in the contract, and only as long as the agent only further discloses the information back to the contracted provider, Medica, or Medica's contracted designee.

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For more detailed information and support for providers, please feel free to visit the Provider Express website.



REV 12/2022

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