Read this content carefully so you know what services are covered. If you still have questions about which services are covered or need more information about a covered service, contact CBH Member Services.

Second Opinions

You have the right to ask for a second opinion if you are not sure about any medical treatment or service that is suggested for you. A second opinion may give you more information that can help you make important decisions about your treatment. A second opinion is available to you at no cost.

Contact CBH Member Services to ask for the name of another CBH Network Provider to get a second opinion. If there are not any other providers in CBH’s Network, you may ask CBH for approval to get a second opinion from an out-of-network provider.

Prior Authorization

Some services need approval from CBH before you can get the service. This is called Prior Authorization. For services that need prior authorization, CBH decides whether a requested service is medically necessary before you get the service.

Your provider is responsible for asking CBH for prior authorization. CBH will review the provider’s request, and your service will be approved if your needs meet the medical necessity criteria for that service. If CBH denies the request for service(s), a letter will be sent explaining the decision, and those services will not be approved for payment.

Prior authorizations for urgent services can be requested 24 hours per day. CBH will call your provider to let them know if the request was approved or denied within 24 hours of the request.

Prior authorizations for non-urgent services are processed during normal business hours. When a non-urgent service request is received outside of business hours, the request is marked as received on the next business day. CBH will make a decision about non-urgent service requests within two business days of receiving the request.

If CBH does not have enough information to decide the request, CBH must tell your provider within four hours of receiving the request that CBH needs more information to decide the request and allow 14 days for the provider to give CBH more information. CBH will tell you of the decision within two business days after receiving the additional information.

You and your provider will get a written notice telling you if the request is approved or denied and, if it was denied, the reason it was denied.

If you need help to better understand the prior authorization process, talk to your service provider or contact CBH Member Services.

What Does Medical Necessity Criteria Mean?

“Medically necessary” means that a service or medicine does one of the following:

  • It will, or is reasonably expected to, prevent an illness, condition, or disability;
  • It will, or is reasonably expected to, reduce or improve the physical, mental, or developmental effects of an illness, condition, injury, or disability;
  • It will help you to get or keep the ability to perform daily tasks, taking into consideration both your abilities and the abilities of someone the same age.

If you need any help understanding when a service or medicine is medically necessary or would like more information, contact CBH Member Services.

If you or your provider would like a copy of the medical necessity guidelines or other rules that were used to decide your prior authorization request, please visit our listing of Medical Necessity Criteria.

What Services or Medicines Need to Be Prior Authorized?

CBH does not pay for medication. Medications, including medications you take for your behavioral health, are covered by your Physical Health Managed Care Organization (PH-MCO). Please refer to your PH-MCO to find out which medications are covered.

Please refer to the Covered Services Listing to see which services require prior authorization.

What If I Receive a Denial Notice?

If CBH denies a request for a service or does not approve it as requested, you can file a Complaint or a Grievance. If you file a Complaint or Grievance for denial of an ongoing service, CBH must authorize the service until the Complaint or Grievance is resolved. See the Complaints and Grievances section of the website for more detailed information.

Service Descriptions

Emergency Services

Emergency services are services needed to treat or evaluate an emergency medical condition, including a behavioral health condition. An emergency medical condition is a condition that is so severe that a reasonable person with no medical training would believe that there is an immediate risk to a person’s life or long-term health. If you have an emergency medical condition, go to the nearest emergency room, dial 911, or call your local ambulance provider. You do not have to get prior approval from CBH to get emergency services, and you may use any hospital or other setting for emergency care.

Outpatient Services

CBH covers outpatient services for behavioral health needs and substance use disorders. Outpatient services do not require an overnight stay at a hospital. CBH will help arrange for these services at one of our network providers.

Inpatient Hospital Services

CBH covers inpatient hospital services for behavioral health needs and substance use disorders. You must use a hospital in CBH’s network. To find out if a hospital is in CBH’s network, check our online Provider Directory.

If you are outside of the Philadelphia area and need emergency mental health or substance use services, call 911 or go to the closest hospital or clinic to receive emergency care. The emergency provider will contact CBH to ensure payment is arranged.

It is important to follow up with your doctor after you are discharged from the hospital. You should go to all your appointments after you leave the hospital. You will usually have a doctor’s appointment within seven days of your discharge from the hospital.

Outpatient Medications

CBH does not pay for medication. Medications, including medications you take for your behavioral health, are covered by your Physical Health Managed Care Organization (PH-MCO). Please refer to your PH-MCO to find out which medications are covered.

Medication-Assisted Treatment

Medication-Assisted Treatment (MAT) uses medications such as Methadone, Suboxone, or Vivitrol to treat opioid dependence. MAT is covered by CBH. Methadone, Suboxone, Vivitrol, and other medications used to treat opioid dependence are prescribed by CBH’s network providers and covered by your physical health plan. If you have any questions about MAT, you can contact CBH Member Services.

Telehealth

Some services may be provided to you through videoconferencing technology (you talk to your doctor or other provider on an electronic screen). This is called telehealth. The use of telehealth helps members receive hard-to-schedule services more quickly. If you are offered a service through telehealth, you will be given a choice between telehealth services or face-to-face services. The CBH network currently offers limited access to telehealth services.