Employee Services > Employees > Behavioral Health Benefit Administration Program > Benefit Design for University of Penn Health System Members

Details of Coverage Under the PENNCare PPO Plan.

In-Network
(PENNCare PPO network)		 Self-Referred/Out-of-Network
Available Providers Must choose Penn Behavioral Health network providers May choose any qualified provider
Accessing Benefits Referral from a Primary Care Physician is no longer required. For In-Network provider information, Covered Persons and physicians can call 1-888-321-4433 To verify that the selected provider is qualified, call 1-888-321-4433. Submit claims to Penn Behavioral Health for outpatient services. All inpatient admissions should have a pre-service claim determination by calling 1-888-321-4433
Mental Health Benefits
Inpatient 100% coverage for up to thirty-five (35 days) per year when medically necessary and pre-certified by PBH (no co-payment). All care not precertified will receive 70% of the UCR charge as determined by PBH. *** 70% of the UCR charge as determined by PBH after a $240 per admission co-payment for up to thirty-five (35) days per year when medically necessary and pre-certified by PBH. All care not pre-certified will receive 50% of the UCR charge, as determined by PBH after a $240 per admission co-payment for up to thirty-five (35) days per year when medically necessary.***
Outpatient $15 co-payment for up to twenty (20) visits per year when medically necessary and pre-certified by PBH. All care not precertified will receive 50% of the UCR charge as determined by PBH. *** 70% of the UCR charge as determined by PBH, for up to twenty (20) visits per year when medically necessary and pre-certified by PBH. All care not pre-certified will receive 50% of the UCR charge, as determined by PBH for up to twenty (20) visits per year when medically necessary.***
Chemical Dependency Benefits
Inpatient 100% coverage for up to 30 days per year when medically necessary and pre-certified by PBH. All care not precertified will receive 50% of the UCR charge as determined by PBH. *** 70% of the UCR charge as determined by PBH after a $240 per admission co-payment for up to thirty (30) days per year when medically necessary and pre-certified by PBH. All care not pre-certified will receive 50% of the UCR charge, as determined by PBH after a $240 per admission co-payment for up to thirty (30) days per year when medically necessary. ***
The thirty (30) days is a combined benefit for both detoxification and residential treatment
Outpatient & acute intensive outpatient $15 co-payment for up to thirty (30) visits per year when medically necessary and pre-certified by PBH. All care not precertified will receive 50% of the UCR charge as determined by PBH. *** 70% of the UCR charge as determined by PBH, for up to thirty (30) visits per year when medically necessary and pre-certified by PBH. All care not pre-certified will receive 50% of the UCR charge, as determined by PBH for up to twenty (20) visits per year when medically necessary. ***

*** The participant is responsible for payment of charges beyond Usual, Customary and Reasonable or Negotiated rates for all Out-of-Network services.

Pre-Service Claim Determinations:
Some of the services received through this plan must have a pre-service claim determination before they are delivered, to determine if they are medically appropriate and fully covered according to the plan benefit design and the amount of service coverage remaining under that person's specific benefits. Failure to obtain a pre-service claim determination for Non-Preferred Provider services, when required, may also result in a reduction of benefits. This Pre-service claim determination of services is a vital program feature that reviews medical and benefit appropriateness of certain procedures/admissions according to the benefit plan. In certain cases, pre-service claim determinations help determine whether a different treatment may be available that is equally effective and yet less traumatic. Pre-service claim determinations also help determine the most appropriate setting for certain services.

When a Covered Person seeks medical treatment that requires a pre-service claim determination from a preferred (In-Network) provider they are still responsible for obtaining the pre-service claim determination prior to treatment or possibly forfeit the maximum plan reimbursements. If the preferred (In-Network) provider fails to obtain the required pre-service claim determination of services, the individual will be held harmless from any associated financial penalties assessed by the Plan as a result. If the request for a pre-service claim determination is denied, the person will be notified in writing that the admission/service will not be paid because it is considered to be medically inappropriate or not a covered benefit under the Plan. The purpose of the program is to determine what is payable by the Plan. This program is not designed to be the practice of medicine or to be a substitute for the medical judgment of the attending Physician or other health care provider.

Exchange (Conversion) of Benefits:
In both the PENNCare PPO Plan and the PENN Preferred Point of Service Plan (also known as the Aetna QPOS and Keystone POS Plans), Outpatient mental health/psychiatric services shall be covered for the full number of Outpatient session visits or an equivalent number of Partial Hospitalization visits per Benefit Period. For a treatment of Mental Illness, the Covered Person may exchange: (a) on a one (1) for two (2) basis, Inpatient days for additional separate Partial Hospitalization services; or (b) on a one (1) for four (4) basis, Inpatient days for additional Outpatient visits. The maximum number of additional Outpatient visits (in exchange for Partial Hospital or Inpatient days) will be 30 visits. See Mental Health Care / Substance Abuse Benefits "Outpatient Treatment Coverage" or "Outpatient Alcohol or Drug Services Coverage".

In both plans, Members using network providers may receive ECT sessions during inpatient or outpatient treatment when requested by a PENN Behavioral Health Network Provider and pre-certified by PENN Behavioral Health. Members may exchange one (1) Mental Health inpatient benefit day for one (1) ECT session. Members using out of network providers will not be covered for Specialized ECT sessions.

In both Plans, Outpatient drug and alcohol benefits are available for an additional thirty (30) separate sessions of Outpatient or partial hospitalization services per year, which may be exchanged on a two (2) to one (1) basis to receive up to 15 more days on Non-Hospital Residential Alcohol or Drug Treatment (i.e. the Covered Person may exchange on a two (2) for one (1) basis up to thirty (30) separate sessions of Outpatient services per year in order to receive up to 15 additional days of Hospital or Non-Hospital Residential Alcohol or Drug Abuse treatment days.) Any benefits exchanged or exchanged under terms of this provision are subject to, and do not increase, the overall Lifetime Maximum.

Providers must complete an exchange of benefits form from PENN Behavioral Health prior to authorization for conversion of benefits. Forms can be obtained by calling a Penn Behavioral Health utilization review administrator at 1-888-321-4433 or going on line at www.pennbehavioralhealth.org.

Details of Coverage Under the PENN Preferred POS Plan.

In-Network
(PENNCare PPO network)		 Self-Referred/Out-of-Network
Available Providers Must choose Penn Behavioral Health network providers May choose any qualified provider
Accessing Benefits Referral from a Primary Care Physician is no longer required. For In-Network provider information, Covered Persons and physicians can call 1-888-321-4433. To verify that the selected provider is qualified, call 1-888-321-4433. Submit claims to Penn Behavioral Health for outpatient services. All inpatient admissions should have a pre-service claim determination by calling 1-888-321-4433.
Mental Health Benefits
Inpatient 100% coverage for up to thirty-five (35 days) per year when medically necessary and pre-certified by PBH (no co-payment). All care not precertified will receive 70% of the UCR charge as determined by PBH. *** 70% of the UCR charge as determined by PBH after a $240 per admission co-payment for up to thirty-five (35) days per year when medically necessary and pre-certified by PBH. All care not pre-certified will receive 50% of the UCR charge, as determined by PBH after a $240 per admission co-payment for up to thirty-five (35) days per year when medically necessary.***
Outpatient $15 co-payment for up to twenty (20) visits per year when medically necessary and pre-certified by PBH. All care not precertified will receive 50% of the UCR charge as determined by PBH. *** 70% of the UCR charge as determined by PBH, for up to twenty (20) visits per year when medically necessary and pre-certified by PBH. All care not pre-certified will receive 50% of the UCR charge, as determined by PBH for up to twenty (20) visits per year when medically necessary.***
Chemical Dependency Benefits
Inpatient 100% coverage for up to 30 days per year when medically necessary and pre-certified by PBH. All care not precertified will receive 50% of the UCR charge as determined by PBH. *** 70% of the UCR charge as determined by PBH after a $240 per admission co-payment for up to thirty (30) days per year when medically necessary and pre-certified by PBH. All care not pre-certified will receive 50% of the UCR charge, as determined by PBH after a $240 per admission co-payment for up to thirty (30) days per year when medically necessary. ***
The thirty (30) days is a combined benefit for both detoxification and residential treatment
Outpatient & acute intensive outpatient $15 co-payment for up to thirty (30) visits per year when medically necessary and pre-certified by PBH. All care not precertified will receive 50% of the UCR charge as determined by PBH. *** 70% of the UCR charge as determined by PBH, for up to thirty (30) visits per year when medically necessary and pre-certified by PBH. All care not pre-certified will receive 50% of the UCR charge, as determined by PBH for up to twenty (20) visits per year when medically necessary. ***

*** The participant is responsible for payment of charges beyond Usual, Customary and Reasonable or Negotiated rates for all Out-of-Network services.

Pre-Service Claim Determinations:
Some of the services received through this plan must have a pre-service claim determination before they are delivered, to determine if they are medically appropriate and fully covered according to the plan benefit design and the amount of service coverage remaining under that person's specific benefits. Failure to obtain a pre-service claim determination for Non-Preferred Provider services, when required, may also result in a reduction of benefits. This Pre-service claim determination of services is a vital program feature that reviews medical and benefit appropriateness of certain procedures/admissions according to the benefit plan. In certain cases, pre-service claim determinations help determine whether a different treatment may be available that is equally effective and yet less traumatic. Pre-service claim determinations also help determine the most appropriate setting for certain services.

When a Covered Person seeks medical treatment that requires a pre-service claim determination from a preferred (In-Network) provider they are still responsible for obtaining the pre-service claim determination prior to treatment or possibly forfeit the maximum plan reimbursements. If the preferred (In-Network) provider fails to obtain the required pre-service claim determination of services, the individual will be held harmless from any associated financial penalties assessed by the Plan as a result. If the request for a pre-service claim determination is denied, the person will be notified in writing that the admission/service will not be paid because it is considered to be medically inappropriate or not a covered benefit under the Plan. The purpose of the program is to determine what is payable by the Plan. This program is not designed to be the practice of medicine or to be a substitute for the medical judgment of the attending Physician or other health care provider.

Exchange (Conversion) of Benefits:
In both the PENNCare PPO Plan and the PENN Preferred Point of Service Plan (also known as the Aetna QPOS and Keystone POS Plans), Outpatient mental health/psychiatric services shall be covered for the full number of Outpatient session visits or an equivalent number of Partial Hospitalization visits per Benefit Period. For a treatment of Mental Illness, the Covered Person may exchange: (a) on a one (1) for two (2) basis, Inpatient days for additional separate Partial Hospitalization services; or (b) on a one (1) for four (4) basis, Inpatient days for additional Outpatient visits. The maximum number of additional Outpatient visits (in exchange for Partial Hospital or Inpatient days) will be 30 visits. See Mental Health Care / Substance Abuse Benefits "Outpatient Treatment Coverage" or "Outpatient Alcohol or Drug Services Coverage".

In both plans, Members using network providers may receive ECT sessions during inpatient or outpatient treatment when requested by a PENN Behavioral Health Network Provider and pre-certified by PENN Behavioral Health. Members may exchange one (1) Mental Health inpatient benefit day for one (1) ECT session. Members using out of network providers will not be covered for Specialized ECT sessions .

In both Plans, Outpatient drug and alcohol benefits are available for an additional thirty (30) separate sessions of Outpatient or partial hospitalization services per year, which may be exchanged on a two (2) to one (1) basis to receive up to 15 more days on Non-Hospital Residential Alcohol or Drug Treatment (i.e. the Covered Person may exchange on a two (2) for one (1) basis up to thirty (30) separate sessions of Outpatient services per year in order to receive up to 15 additional days of Hospital or Non-Hospital Residential Alcohol or Drug Abuse treatment days.) Any benefits exchanged or exchanged under terms of this provision are subject to, and do not increase, the overall Lifetime Maximum.

Providers must complete an exchange of benefits form from PENN Behavioral Health prior to authorization for conversion of benefits. Forms can be obtained by calling a Penn Behavioral Health utilization review administrator at 1-888-321-4433 or going on line at www.pennbehavioralhealth.org.