TO:                   EAN PROVIDERS
FROM:             EAN
RE:                   NEW PROCEDURES FOR EAN PROVIDERS
DATE:              JUNE 25, 2010

 The guidance contained in this memorandum only applies to the two Health Plans listed below. Please continue to follow established procedures for the other health plans managed by EAN. Instructions for those plans will be issued prior to January 1, 2011.

 Biltmore Company Health Plan                                        City of Asheville Health Plan

 Effective July 1, 2010, The Biltmore Company Health Plan and the City of Asheville Health Plan will begin their new plan years. As required by law, these two plans have been amended to be compliant with the Mental Health Parity and Addiction Equity Act of 2008. EAN will be implementing changes to the management of the above referenced Health Plans. EAN will cease our pre-authorization process and transition to a case review and case management model. This new model is based on an outlier system and designed to be substantially equivalent to medical management models used for medical/surgical care. The following guidance pertains to these two plans only. EAN’s new procedures are effective July 1, 2010.

 New Clients and Active Established Clients

 Effective July 1, 2010, as an EAN provider you will not be required to obtain pre-authorization before delivering services to clients covered by the Biltmore Company Health Plan or the City of Asheville Health Plan.  During the course of the Plan year, July 1, 2010 through June 30, 2011 a client may use a total of twelve (12) sessions without triggering a review. Case review to determine ongoing medical necessity and assignment of an EAN Case Manager will be initiated when the number of sessions exceeds twelve (12).  If the course of treatment or the episode can be contained within twelve (12) sessions it will not be necessary to review the case with EAN. File claims according to the usual procedures. As in the past, feel free to contact EAN with any issues or questions.

If you anticipate that the client will require more than twelve (12) sessions, we strongly encourage you to file an EAN Clinical Evaluation Form. You may file this form with EAN as early in the treatment process as you feel is practicable but no later than after session ten (10). A copy of this form is enclosed or it may be downloaded from our website:  www.eannc.com.

 It is important to understand that sessions are counted by the third party administrator based on the accumulation of claims submitted by all behavioral health providers. Therefore, it may be helpful for you to know if your client is also being treated by another provider.

 Health plan members will continue to be encouraged to obtain referrals from EAN so you will still receive referrals to your practice directly from EAN clinical staff. However health plan members will no longer be required to contact EAN prior to initiating services with you. Typically you will receive a phone call from the EAN clinician about the referral, or the health plan member will contact you directly.  You will not receive a faxed or mailed authorization form.

Request for Additional Services
 

Clinical Evaluation Form (07/10)
 

Verification of Continued Medical Necessity (07/10)

Summary of Treatment Progress
(insured through: 
Transylvania Regional Hospital;
Sisters of Mercy;
CarePartners Health Services)

Summary of Treatment Progress
(insured through: 
City of Asheville;
Biltmore Company;
Blue Ridge Hospital;
Grove Park Inn; MAHEC;
McDowell Hospital;
Mission Hospitals;
Pardee Memorial Hospital)

Treatment Summary Guidelines

Levels of Care Criteria (06/09)

Plan Limits & TPA Contract Information