Insurance

Information regarding the patient’s insurance coverage may come from the patient or associates, family members, insurance card, MGH computer, BEST, or the last hospital to admit the patient.

Hospital placement requirements

1. verification of insurance benefits

2. precertification by insurer’s reviewer (not required by Medicare)

- document authorization number, who approved, how many days

3. acceptance by a hospital and name of accepting MD

The procedure for hospitalization depends on whether the patient has private insurance, Medicare, Medicaid (MassHealth) or no insurance as outlined in the following sections.

STEP 1: PRIVATE INSURANCE

This includes HMOs, PPOs, POSs and Indemnity Plans. Contact the carrier early in assessment, since evaluation or hospitalization at specific centers may be required. Telephone numbers are given on back of card or in table below. APS staff can help verify insurance on any APS patient. Registration verifies benefits for EW patients.

a. If Blue Cross / Blue Shield :

1. Verify by calling the BC/BS Operator (800 524-4010).

2. Follow their instructions regarding evaluation, precertification,

and hospitalization.

BC/BS plans include:

Indemnity plans (Master Medical, Master Health, Major Medical,), preferred provider organizations (PPOs: Blue Care Elect), health maintenance organizations (HMOs: HMO Blue, now including Bay State), point of service plans (POSs: HealthFlex Blue, Blue Choice), Medicare supplements (Medex) and Medicare benefit substitute management (Blue Care 65). Partners Plus is a BC/BS product administered by MGH.

b. If Pilgrim Joint Venture Or Pilgrim Prime 65 Or Tufts Secure Horizons Or Blue Care 65 (these are MGH Department of Psychiatry capitated contracts):

1. Verify benefits with appropriate telephone operator:

Pilgrim Joint Venture 1-800-742-8326

Pilgrim Prime 65 1-800-742-8326

Tufts Secure Horizons 1-800-701-9000

Blue Care 65 1-800-222-7620

2. You will know they are MGH capitated patients if their PCP is MGH or MGH Health Center-based. When in doubt, ASK APS front office or EW registration staff!

Important: If you are directed by an individual at one of the above 1-800 numbers to consult or not to consult an MGH reviewer for authorization, document name of that individual in the APS chart.

3. For precertification, from 8:30A to 5P, M-F, contact Dr. Jeff Weilburg at 6-3396 or page at 6-3591; after hours, page MGH Attending Psychiatrist on-call posted in APS.

4. For Pilgrim Prime 65, Tufts Secure Horizons, and Blue Care 65, you must call the PCP for final authorization after discussing the case with MGH Attending Psychiatrist on-call. It is not necessary to call the PCP for Pilgrim Joint Venture.

c. If Tufts (except Secure Horizons):

1. Call 800-672-1515 M-F, 9AM TO 5PM OR Call 800-955-8825 after-hours and on weekends OR number on card for verification and instructions.

2. Transfer for evaluation or hospitalization as instructed.

3. If Patient has Tufts AND has an MGH or BWH PCP, they are part of the MGH/McLean Designated Facility Capitated contract. The APS and the CEC are the authorized entry points for hospital level of care for Psychiatric or Substance Abuse problems. Call 1-888-345-4009 and follow instructions.

Cathy Horan (Total Tufts) ………..972-2060 (M-F 9am-9pm)

Otherwise page Tufts attending on call.

d. If Harvard Pilgrim Health Plan:

1. For verification and instructions, between 9A and 5P, M-F, call subscriber’s HCHP Center; after hours, call 522-4400 x300. For verification only: 617-509-1000.

2. Transfer for evaluation or hospitalization as instructed.

e. If MIT Health Plan:

1. Call 253-2916 (day), 253-4481 (night) for verification and precertification.

2. Hospitalize as instructed

f. if insurance cannot be verified:

Any hospital accepting patient’s insurance may decide to accept pt, expecting to verify benefits later. This is more likely if the insurer is a major carrier, patient is employed, hospital has previously admitted patient, and so forth. McLean Hospital has been very helpful in this regard. Some families may advance cash payment to a private hospital to secure admission for patient. Typically this requires $10,000 - $15,000.

*** For all plans marked with *** in the following table who have a PCP at the MGH, the MGH attending psychiatrist must be called to approve admission: Between 8:30A-5P, M-F call J. Weilberg (63396). After hours page attending psychiatrist per schedule in APS. For Pilgrim Prime 65, Tufts Secure Horizons and Blue Care 65 PCP must also be called to approve admission.

Private Insurance Numbers

STEP 2: MEDICARE

Medicare is insurance administered by the federal government for the elderly or disabled. Part A is inpt benefits, Part B is outpt benefits. There is a lifetime limit of 160 psychiatric inpt days that can be used by private psych hospitals. After that limit has been used, there is unlimited inpt days for psych units in general hospitals.

1.Contact potential accepting hospital, who will be able to verify coverage. The hospital which most recently admitted pt may know coverage and psych days remaining.

2. If pt HAS PSYCH DAYS REMAINING (lifetime maximum 160): any hospital can accept pt.

3. If pt HAS NO PSYCH DAYS REMAINING: pt must be hospitalized in a general hospital.

NOTE: Some MassHealth patients have Medicare or private insurance as primary insurance and may be verified by MassHealth (see below): a “Third Party Liability” will appear on POS machine print out (8400 = Part A, 8500 = Part B; codes for other insurers can be interpreted by BEST).

STEP 3: MASSHEALTH, NOT CATEGORY 4

MassHealth, a synonym for Medicaid, is a state program, which subcontracts care to various insurance providers, chiefly MBHP (Massachusetts Behavioral Health Partnership) and NHP (Neighborhood Health Plan) and HealthNet (a BMC-based plan). Some few pts have Medicare or commercial insurer instead. (New pts may have temporary cards, which indicate MassHealth eligibility start/stop dates and category. The Human Operator can verify coverage, but the POS or Automated lines usually cannot).

1.Verify coverage and provider by one of three methods (will need MGH Provider # 120 2154):

POS Machine (instructions on machine; RID # from card and DOB required); or

Human Operator (800-833-7582; name and DOB, or Social Security #, required; the Human Operator is necessary if card number not known); or

Automated Operator (800-554-0042; if POS connection inoperative).

2. If you have a specific hospital where you want the patient admitted, make sure there is a bed available at that hospital. The hospital will tentatively say they are likely to take patient pending MBHP authorization. This saves time and extra phone calls as you continue this process!

3. If MassHealth patient is covered by MBHP:

a.. call 1-800-998-6462, request emergency psychiatric admit,

b. present case, discuss the hospital choice

c. Record authorization number (which is specific to admitting hospital), number of days authorized and reviewer’s name on the Door Sheet and in the plan section of the EDDS note.

4.If NHP/Beacon: call 1-800-414-2820.

5.If PARAMAX (no assigned insurance provider for inpt psychiatric care): consult BEST.

STEP 4: NO INSURANCE or MASSHEALTH, CATEGORY 4

The process for managing hospitalization of the uninsured varies every year. This year, MBHP oversees the free care bed search. Once general hospital psych beds have been exhausted, you call MBHP for permission to use a “free care” bed at one of MBHP’s network private psychiatric hospitals. See table of “order of free care bed search” below.