Are You Receiving Outpatient Mental Health, Substance Abuse or Physical Therapy Treatments? Learn How the Health Plan Covers These Treatments.

The Health Plan covers visits for outpatient mental health, substance abuse and physical therapy services with no preauthorization required, as long as the services are considered Medically Necessary under the terms of the Plan. However, because a typical course of treatment for these services might continue over an extended period of time, the Health Plan has established procedures (referred to as the “20/30 visit” procedures) for evaluating the Medical Necessity of ongoing treatment. The Health Plan has been applying these 20/30 visit procedures for many years, and you may already be familiar with them.

Under the Health Plan’s 20/30 visit procedures, all participants and beneficiaries must demonstrate that ongoing treatment for mental health, substance abuse or physical therapy beyond 30 visits is Medically Necessary. As a courtesy, the Health Plan will send notification to participants and beneficiaries after receiving the 20th claim for a single course of treatment to remind them that they must demonstrate Medical Necessity for ongoing treatment after the 30th visit to be covered. NOTE: The Health Plan may confirm Medical Necessity for a service or course of treatment prior to the 31st claim.

Recently, the Board of Trustees amended the Health Plan’s Summary Plan Description (“SPD”) to add a description of the 20/30 visit procedures in order to help ensure that participants are aware of the process when receiving these types of treatments.

For further details, please refer to the newly added explanation of the 20/30 visit procedures in Article IV, Section 11 of the March 2020 Health Plan Summary Plan Description at www.dgaplans.org/health-plan-booklet, or contact the Health Plan for a hard copy to be sent to you at no cost.

The 20/30 Visit Procedures

The 20/30 visit procedures help the Health Plan determine when continued visits for an ongoing course of treatment are Medically Necessary, and therefore, eligible for continued coverage.

1. Claims for visits 1-19. You are receiving outpatient mental health, substance abuse or physical therapy services as part of a single course of treatment. If claims have been filed timely and all other requirements for Plan coverage—including Medical Necessity—are met, these visits would normally be covered.
2. Claim for visit #20. The Health Plan notifies you and your doctor that, at 30 visits, your medical records will need to be provided for review to confirm the Medical Necessity of continued treatment. The Health Plan can also arrange for a peer-to-peer review to discuss Medical Necessity directly with your provider. At this point, the Health Plan continues covering treatment.
3. Claim for visit #30. The Health Plan sends you and your doctor a notice requesting medical records for review to confirm the Medical Necessity of continued treatment beyond 30 visits.
4. Claims for visit #31+. The Health Plan will deny coverage on subsequent claims after the 30th visit, pending the Health Plan’s receipt of the requested records and review an approval for Medical Necessity. You are encouraged to work with your provider to ensure that the requested information is submitted to the Health Plan in a timely manner and no later than 180 days from the date of the notice. The Health Plan can also arrange for a peer-to-peer review to discuss Medical Necessity directly with your provider. The results of the evaluation for Medical Necessity will determine whether these and subsequent visits will be covered and at what interval additional Medical Necessity reviews will be required.

Important Considerations to Keep in Mind

• File claims timely. Filing claims as they are incurred keeps you aware of where you are in the process so that you can make an informed decision on how to proceed. If your provider is a non-network provider and you are submitting claims for reimbursement, it is best not to wait and file claims in bulk, as you may find out after the fact that your claims are determined to be not Medically Necessary. You are responsible for the full cost of any claims determined to be not Medically Necessary.

  If your treatment is rendered by a network provider, who will typically file claims on your behalf, use your myPHP benefits portal account (www.dgaplans.org/about-myphp) to monitor whether your claims are being filed timely. As your claims are processed, you should receive the corresponding explanations of benefits (“EOB”) in the Health Eligibility tab of your myPHP account. Although non-network providers must submit claims within one year of the date of service, and network providers must submit claims within the timeframe defined in their contracts, if you find that your EOBs are taking too long to appear in your myPHP account, contact your provider to verify they are submitting your claims timely (and not waiting to submit them in bulk).

• Respond to Health Plan requests for information by the date requested. Failure to provide required information timely will result in automatic denial of claims under review, pending receipt of information sufficient to confirm Medical necessity.
• Maintenance programs are always considered not Medically Necessary. A maintenance program consists of treatments or activities that preserve the individual’s present level range, strength, coordination, balance, pain, activity, function, etc., and prevent regression of the same parameters. Maintenance begins when the therapeutic goals of a treatment plan have been achieved, or when no additional functional progress is apparent or expected to occur.
• The Health Plan is not prohibited from confirming Medical Necessity for a service or course of treatment prior to the 31st claim. This includes courses of treatment of unusual or irregular duration, frequency, or scope of services provided over a period of time.
• When in doubt, contact the Health Plan. If you are undergoing a course of treatment for physical therapy, mental health, or substance abuse and have surpassed 20 visits with no request for further information from the Health Plan, you are encouraged to contact the Health Plan Participant Services at (323) 866-2200, Ext. 401, to check where you are in the 20/30 visit evaluation process or for any other information regarding your claims status.