Access to outpatient behavioral health services

These services may or may not be covered by all CoOportunity Health plans. Please see your plan documents for your own coverage information. If there is a difference between this general information and your plan documents, your plan will be used to determine your coverage.

Administrative process

Prior authorization may be required for specific outpatient services. For assistance in finding a contracted network provider, members may call 1-888-324-2064.

Access to routine outpatient behavioral health services for evaluation and treatment of mental health and substance use disorders as described in the most recent version of the Diagnostic and Statistical Manual of Mental Disorders (DSM) are covered per the indications listed below.

Not all benefit plans allow in-network coverage for out-of-network providers or have out-of-network benefits. For plans that have out-of-network benefits, the out-of-network benefits are to be used for providers that are not in the contracted provider network.

Indications that are covered at the in-network benefit level

Out-of-network providers may be covered at the in-network benefit level if your benefit plan allows and if the following conditions are met:

1. The service must be covered under the terms of the benefit plan; and
2. The service must be medically necessary; and
3. The services must be provided by a behavioral health professional that is licensed for independent practice; and
4. CoOportunity Health has determined that the service is not available within the contracted provider network by a behavioral health professional licensed for independent practice and authorizes the service to be provided outside of the contracted provider network.
   
   1. Up to ten calls to contracted providers will be made by the CoOportunity Health administration to determine if they have appointments available within ten business days to treat the diagnosed condition.
   2. When access to a contracted provider is not available within ten business days to treat the diagnosed condition, referrals out-of-network may be considered with coverage at the in-network benefit to ensure access to the needed care.

Indications that are not covered

Referrals out of network will not be made for coverage at the in-network benefit level when care is available to treat the diagnosed condition with a contracted provider.

Direct Provider Network - Contracted providers that members can access for in-network coverage. These providers do not require authorization by CoOportunity Health unless the service they provide requires authorization.

If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.

 

This information is for most, but not all, CoOportunity Health plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

CoOportunity Health has contracted with HealthPartners Administrators, Inc. to provide claims processing, medical management and certain other administrative services.