Close-Up:
Rebecca And Ronnie

Rebecca and her daughter, Ronnie, have had a tough year. Rebecca has had a series of unhappy personal and professional experiences and would like to see a therapist for counseling. Ronnie has a serious mental illness - she has been diagnosed with bulimia nervosa.

Rebecca is enrolled in the Regular Plan. Her friend Charlotte recommends her therapist, who isn't a OptumHealth Behavioral Solutions provider, and Rebecca makes an appointment to see him. But at the last minute, Rebecca refers to her Summary of Benefits and discovers that if she sees a non-OptumHealth Behavioral Solutions provider, the plan will pay 70% of R&C charges, whereas if she sees a OptumHealth Behavioral Solutions provider, she'll pay just a $15 copay. In addition, the plan covers up to 20 outpatient visits a year with a non-OptumHealth Behavioral Solutions provider compared with up to 45 outpatient visits a year with a OptumHealth Behavioral Solutions provider. Rebecca makes some calls and gets the name of a OptumHealth Behavioral Solutions provider, who she can see for up to 45 outpatient visits a year by just paying a copay for each visit, assuming she obtains precertification.

Ronnie is also enrolled in the Regular Plan. Because her therapist is a non-OptumHealth Behavioral Solutions provider, the plan covers a maximum of 20 outpatient visits a year. After Ronnie's 20 visits, her therapist recommends that Ronnie be admitted to a mental health facility. Rebecca realizes that the plan will pay higher benefits if Ronnie goes to an inpatient OptumHealth Behavioral Solutions facility, so she and the therapist obtain precertification for inpatient treatment at a OptumHealth Behavioral Solutions facility.

How To Percentify Mental Health And/Or Substance Abuse Care
To receive the highest level of benefits, you need to see a OptumHealth Behavioral Solutions provider, who will work with OptumHealth Behavioral Solutions to precertify your care. It is your responsibility, however, to first call OptumHealth Behavioral Solutions to verify that the provider is in the OptumHealth Behavioral Solutions network. You must also make sure the provider precertifies your initial and ongoing care, which must be considered medically necessary in order to be authorized by OptumHealth Behavioral Solutions. If you go to a OptumHealth Behavioral Solutions provider but don't precertify your care, your benefits will be paid at the non-OptumHealth Behavioral Solutions level and will be subject to non-OptumHealth Behavioral Solutions provider limits.

Precertification (for OptumHealth Behavioral Solutions providers) is required for:

• All inpatient admissions for mental health care; and
• All outpatient mental health treatment.

Generally, you should precertify inpatient treatment 7 to 10 days in advance by calling OptumHealth Behavioral Solutions. Any facility-based treatment - for example, inpatient rehabilitation, partial hospitalization*, residential treatment* or an intensive outpatient program - that is pre-planned should be precertified ahead of time.

If you're admitted to the hospital or other facility because you have a mental health emergency, you must precertify within 48 hours (or two business days) of your admission by calling OptumHealth Behavioral Solutions. Your case will be assigned to a team of clinical care managers.

During a stay at a hospital or mental health facility, you may not use your outpatient benefits.

* For benefit purposes, one partial hospitalization or residential treatment day is equal to one inpatient hospitalization day.

* Beginning October 1, 2004, for benefit purposes, intensive outpatient visits are equal to one outpatient visit.