Effective January 1, 2011, all Employer Health Plans managed by EAN will have been amended to be compliant with the Mental Health Parity and Addiction Equity Act of 2008. EAN will use a case review and case management model which is a model based on an outlier system and is designed to be substantially equivalent to medical management models used for medical/surgical care.
New Clients and Active Established Clients
Effective January 1, 2011, providers will not be required to obtain pre-authorization before delivering services to clients whose health plan is managed by EAN. During the course of the Plan year, 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. Providers can file claims according to the usual procedures. As in the past, provider can contact EAN with any issues or questions.
If a provider anticipates that the client will require more than twelve (12) sessions, we strongly encourage you to file an EAN Clinical Evaluation Form. Providers may file this form with EAN as early in the treatment process as practical but no later than after session ten (10). Medication management will not be included in case reviews, all other EAN service codes will be subject to the review. If providers have a question about service codes and reimbursement, we encourage them to contact EAN.
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 providers to know if the health plan member is also being treated by another provider.
Health plan members will still be encouraged to obtain referrals from EAN so providers will still receive referrals directly from EAN clinical staff; however, health plan members will no longer be required to contact EAN prior to initiating services through their insurance. Typically a provider will receive a phone call from the EAN clinician about the referral, or the health plan member will contact the provider directly.