The Employee Assistance Program (EAP) and behavioral health benefits are administered by Optum®.
New in 2020 -- All members will get an Optum ID card.
New - available now: Costs are waived for members who use certain preferred substance use treatment facilities.
- PPO members who use these high-quality facilities won’t pay a deductible or coinsurance for facility-based substance use treatment.
- CDHP/HSA members’ coinsurance is waived after they meet their deductible.
- Copays, deductible and coinsurance will still apply for standard outpatient treatment services.
Behavioral health eligibility
Behavioral health benefits are available to members and dependents enrolled in medical insurance.
Behavioral health services
Whether you are dealing with a mental health or substance use condition, support is available through your behavioral health coverage. Your enrolled dependents can use these benefits too.
Optum is your behavioral healthcare vendor. Using one of Optum’s network providers gets you the most from this benefit, which is included when you and your dependents enroll in a health plan.
Behavioral health assistance includes, but is not limited to:
- Explaining your benefits
- Identifying the best treatment options
- Helping you find a provider
- Helping you schedule an appointment
- Answering your questions
In addition to office visits, this benefit includes virtual visits. With virtual visits, you can meet with a provider through private, secure video conferencing. It allows you to get the care you need sooner and in the privacy of your home.
- Virtual visit copays are the same as an office visit. To get started, go to Here4TN.com, scroll down, select provider search, and filter results by virtual visits to find a provider licensed in Tennessee, or call 855-Here4TN for assistance.
To receive maximum benefit coverage, participants must use a network provider. For help finding a network provider, call 855-Here4TN. Optum can even help you schedule your appointments for you when you call. Preauthorization is required for non-routine outpatient and all inpatient services. A provider directory with a search feature is available on the website.
You can learn more by visiting Here4TN.com or calling855.HERE.4.TN (855.437.3486) toll free, any time, day or night, to speak confidentially with a trained professional for a referral or preauthorization.
Here4TN.com also has resources, articles and other helpful information about your behavioral health services.
Participants may see an out-of-network mental health provider without calling for a referral; however, coinsurance and copayments will be higher. Participants are also subject to balance billing by the out-of-network provider, meaning that they will pay the difference between the maximum allowable charge and the actual charge. In addition, participants are at risk of having inpatient benefits totally denied. Certain services are specifically excluded under the terms and conditions of the state group insurance program.
Opioid/substance use disorder help
Opioids are strong pain medicines used to relieve moderate to severe pain. They can help you manage pain when you use them the right way. But if you misuse them, they can cause serious harm and even death. Opioid use disorder means using these drugs in a way that keeps you from living the life you want. When your use is out of control, it harms you and your relationships.
Treatment usually includes medicines, group therapy, one or more types of counseling, and drug education. There is no “one-size-fits-all” solution because everyone’s situation is unique. An individualized treatment strategy begins with an assessment by a licensed clinician. In general, treatment options may include one or more of the following:
- Detoxification: medical management of the physical symptoms of withdrawal from drugs or alcohol
- Local, short-term, intensive residential treatment: 24 hour treatment with MD and RN staff
- Medication-assisted treatment: the use of approved medications in combination with therapy to treat substance use disorders
- Intensive outpatient treatment: 3-5 days a week up to 3 hours of individual and group therapy
- Individual substance use disorder counseling: individual therapy with an outpatient provider
- Group therapy: group of patients meet to discuss issues under the guidance of a therapist
Many people with this disorder, and sometimes their families, feel embarrassed or ashamed. Don't let these feelings stand in the way of getting treatment. Remember that the disorder can happen to anyone who uses opioids, no matter what the reason.
If you are enrolled in the state health plan, call Optum today and get the help you need. Call 855-Here4TN (855-437-3486) 24/7, or go to Here4TN.com.
Behavioral health service appeals
If you are in disagreement with a decision or the way a claim has been paid or processed, you or your authorized representative should first call member service at Optum: 855-HERE-4-TN to discuss the issue.
First Level Appeal — If the issue cannot be resolved through member service, the member or his/her authorized representative may file a formal request for internal review or member grievance by contacting Optum. All requests must be filed within the specified timeframes. When your request for review or member grievance is received, you will get an acknowledgement letter advising you what to expect regarding the processing of your grievance. Once a determination is made, you will be notified in writing and advised of any further appeal options including information about how to request an external review of their case from an independent review organization (IRO).
Second Level Appeal — If the member's first level appeal is denied, the member or his/her authorized representative may file a second formal request for internal review or member grievance by contacting Optum. All requests must be filed within the specified timeframes. When your request for review or member grievance is received, you will get an acknowledgement letter advising you what to expect regarding the processing of your grievance. Once a determination is made, you will be notified in writing and advised of any further appeal options including information about how to request an external review of their case from an independent review organization (IRO).
External Review — If the member's first and/or second level internal appeal is denied, the member or his/her authorized representative may choose to request that an IRO review the case and make a final determination. The IRO will communicate their decision to the member. This decision will be final and binding on the member, the plan and the Carrier.
The appeals/grievance form can be initiated by contacting Optum. Members will have 180 days to initiate an internal appeal following notice of an adverse determination. Notification of decisions will be made within the following time frames, and all decision notices shall advise of any further appeal options:
- No later than 72 hours after receipt of the claim for urgent care
- 30 days for denials of non-urgent care not yet received
- 60 days for denials of services already received
Services and resources
- Online resources can be accessed via Here4TN.com
- More than 5,000 articles, videos, podcasts, webinars and newsletters
- Self-assessments and personal plans