Highmark Commercial Medical Policy - Pennsylvania |
Medical Policy: | V-39-008 |
Topic: | Mental Illness Coverage |
Section: | Visits |
Effective Date: | October 1, 2016 |
Issue Date: | October 3, 2016 |
Last Reviewed: | June 2013 |
Effective April 19, 1999, Act 150-1998, (Mental Health Benefit Mandate) requires coverage for serious mental illnesses for at least thirty (30) inpatient days/visits and sixty (60) outpatient days/visits annually. Coverage of inpatient visits/days can be converted to outpatient visits/days on a one-for-two basis. As defined by Act 150-1998, "serious mental illness" means any of the following mental illnesses as defined by the American Psychiatric Association in the most recent edition of the Diagnostic and Statistical Manual:
Coverage for the services defined in Act 150-1998, are subject to any copayments, coinsurance or deductibles, and all other terms and conditions, set forth in the patient's contract. NOTE: This applies to group business. In some Plan areas, it applies only to groups of 50 or more. |
This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.
Policy Position Coverage is subject to the specific terms of the member’s benefit plan. |
Place of Service: Inpatient/Outpatient |
Mental Illness Coverage is typically provided as an oupatient and is only eligible for coverage as an inpatient in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.
The policy position applies to all commercial lines of business |
Denial Statements |
A network provider can bill the member for the non-covered service.
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