Behavioral Health

Behavioral Health Services - Outpatient

No prior authorization is required for in-network Behavioral Health counseling and therapy, including visits with a psychiatrist (MD) as of January 1, 2022. You are no longer required to request this type of referral from your Primary Care Provider (PCP), although you may want to discuss your need for this type of service with your PCP. Your PCP can be helpful in ways other than arranging for Behavioral Health Counseling Services.
 
To access outpatient Behavioral Health Counseling Services, you may contact a VHP Behavioral Health Provider directly or you can contact the VHP Member Services at 1.888.421.8444 (toll-free) for assistance in obtaining care.  You can also use our 
Provider Search to find a Behavioral Health Provider near you!

Medical and Behavioral Health appointments for all members visit MDLIVE today!

MDLIVE thousands of doctors are standing by and ready to help.

Behavioral Health Services – Inpatient

Your VHP Behavioral Health Provider will make arrangements for covered services when Medically Necessary. 

Behavioral Health Benefits and Claims

Call VHP Member Services at 1.888.421.8444 (toll-free) for assistance with mental health benefits, coverage, and claims processing information.

Mental Health as a Medical Necessity

VHP will cover your mental health and substance abuse treatment under the following circumstances:

  • The treatment is considered “medically necessary”
  • The treatment is covered by your benefit plan
  • The treatment is administered from a contracted healthcare provider.

What does “medical necessity” mean for mental health and substance abuse treatment?

“Medically necessary” treatment of a mental health or substance use disorder means a service or product addressing the specific needs of that member, for the purpose of preventing, diagnosing, or treating an illness, injury, condition, or its symptoms, including minimizing the progression of that illness, injury, condition, or its symptoms, in a manner that is all of the following:

  • Meets the generally accepted standards of mental health and substance use disorder care.
  • Clinically appropriate in terms of type, frequency, extent, site, and duration
  • Not primarily for the economic benefit of the health care service plan and members or for the convenience of the patient, treating physician, or other health care provider.

How does Valley Health Plan determine “medical necessity” for mental health and substance abuse treatment?

VHP determines the medical necessity of health care services for mental health and substance use disorders based on the guidelines of professional clinical associations.

The following guidelines are used for the evaluation mental health treatment:

Early Childhood Service Intensity Instrument (ECSII)

Level of Care Utilization System for Adults, Adolescents and Children

The following guidelines are used for the evaluation of substance abuse treatment:

The ASAM Criteria

The following guidelines are used for the evaluation and treatment of gender dysphoria:

https://www.wpath.org/soc8

Please contact member services for additional information on the guidelines above 1.888.421.8444.

©2022 County of Santa Clara. All rights reserved.