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Out-of-Network Coverage for Mental Health and Substance Use Disorder Services

If VHP’s in-network providers are not available within the required time or distance, VHP will arrange and cover the MH/SUD service from an out-of-network provider.

If VHP provides and arranges for out-of-network coverage due to our in-network inadequacy, you will receive a written notice within five (5) calendar days stating: 

  • VHP will arrange and pay for out-of-network services because an in-network provider is not available within the required timeframe or geographic area
  • You are only responsible for paying your usually in-network cost sharing for the medically necessary MH/SUD service

If MH/SUD services are not available to you from an in-network provider within the geographic and timely access standards, VHP will provide and arrange coverage for medically necessary MH/SUD services from an out-of-network provider or providers within the following timeframes unless CA Health and Safety Code (HSC) Section 1367.03(a)(5)(H) or (a)(5)(I) apply: 

  • No more than 10 business days after the initial request for non-urgent MH/SUD services
  • Within 15 business days of a request for a specialist physician MH/SUD services
  • Within 48 hours of the initial request for urgent MH/SUD services if no prior authorization is required
  • Within 96 hours of the initial request for urgent MH/SUD services if prior authorization is required

Within 24 hours of the scheduling of the out-of-network appointment or admission accepted by the member, VHP must provide you, your authorized representative or your provider with information regarding the appointment or admission. 

If VHP is not able to arrange for covered the MH/SUD service in-network, you or your authorized representative is permitted to arrange for care from any appropriately licensed provider as long as the appointment or admission occur no more than 90 days after the initial request for services. 

If an appointment or admission to a provider is not available within 90 calendar days of initially submitting a request, you may arrange an appointment or admission for the earliest possible date outside the 90-day window so long as the appointment or admission was confirmed within 90 days. 

If out-of-network coverage is obtained because VHP does not have an in-network provider available within the required timeframe or geographic area, VHP will reimburse the out-of-network provider for the entire course of medically necessary services unless:

  • There is an in-network timely and geographically accessible provider available to deliver MH/SUD services; and/or
  • Transfer to the new provider would not harm the member and transfer is within the standard of care for the member’s MH/SUD condition. 

Before VHP transitions you to an in-network provider, VHP will provide you, your authorized representative (if any), and the treating provider(s) with at least 90 calendar days’ notice. 

The notice will contain following information:

  • Name and contact information of the in-network provider you will be transitioned to
  • How you may file a complaint with VHP if you, your authorized representative or your provider believes transitioning you to an in-network provider will harm you or is not within the standard of care

VHP shall be responsible for making the decision (determination) for medically necessary MD/SUD service in accordance with good professional practice and with the clinical standards set forth in sections 1374.721 and 1374.722. 

VHP will also keep a record of the determination and underlying analysis, rationale, and other supporting documentation for the full range of medically necessary MH/SUD services. 

When VHP delays, denies, or modifies MH/SUD services requested by an you, your authorized representative, or your provider, VHP will send a written communication including the information listed below: 

  • The MH/SUD condition(s) for the requested service
  • The clinical specialty at issue
  • List of all criteria or guidelines used
  • Summary of the reasons from deviating from the criteria, if applicable
  • Summary of the clinical reason(s) for the decision

Within 30 calendar days of the request, VHP will provide all utilization review determination criteria and any education program materials to the requesting party (you, your authorized representative, and your requesting provider) at no cost in one or more of the following ways: paper form, electronically by email, or website.

If you have any questions, please contact VHP Member Services at 888-421-8444 (toll-free) from 9 AM to 5 PM or email [email protected].