Background: Every member of an AMBHA managed behavioral healthcare organization (MBHO) shall have a choice of behavioral healthcare providers (within the network) made available to him/her. AMBHA advocates that services be provided in coordinated and integrated delivery systems using the most cost-effective approaches to providing quality care. This requires significant involvement of providers who have both the clinical skills and organizational systems associated with the delivery and demonstration of positive clinical outcomes and positive consumer satisfaction. Carefully developed and selected delivery systems allow choice and promote accountability and efficiency. AMBHA member companies also support ongoing development and training of clinicians.

Background: AMBHA members are committed to continuous quality improvement and seek to be held accountable for the quality of services they deliver. To demonstrate this commitment, AMBHA released PERMS 2.0 in September 1998. PERMS measures address areas of genuine concern for and interest for a wide variety of groups and stakeholders. Components of PERMS include HEDIS-type reporting, testing set indicators and consumer satisfaction measures.

Background: Consumers shall be guaranteed the confidentiality of their relationships with their behavioral health professionals, except when law dictates otherwise, to assure their safety or the safety of others. The appropriate sharing of clinical information for the purposes of continuity of care should be clearly defined and understood and agreed to by the consumer. Information is shared to promote coordinated, integrated, and effective care. It is the responsibility of MBHOs and other entities (e.g. providers) to ensure that patient records are not used other than for appropriate clinical, quality improvement, financial or legal purposes. Confidentiality guidelines will be consistent with state and federal regulations governing the confidentiality of medical records.

Background: MBHOs want their patients to know and understand why a particular coverage determination is made. If the patient disagrees with the evaluation, he/she can appeal the decision. AMBHA members feel it is of utmost importance to ensure that consumers get appropriate care in a timely fashion and that they understand their options to appeal decisions with which they do not agree.

Background: AMBHA member companies believe that patients should receive the right care at the right time in the most appropriate setting. A patient's treatment plan should be developed based on evidence-based guidelines. Only qualified clinical personnel should be authorized to make clinical decisions.

Background: AMBHA member companies believe that in order for consumers to receive the right care at the right time, they must be equipped with information. Further, AMBHA member companies recognize the importance of cultural competency and diversity. Upon purchase of health coverage, consumers shall be informed, in language they can understand, of the extent of their behavioral health benefits and of the available appeals and grievances processes. If requested by a network provider or member, AMBHA MBHOs will also furnish treatment guidelines or explain how to obtain treatment guidelines.

Background: AMBHA recognizes the importance of having appropriate timelines and accuracy standards for reimbursement of care. Any standardized timelines and accuracy measures should be operationally reasonable and consistent with the delivery of good clinical care. Payment timelines should be consistent with state and federal guidelines.

Background: Formularies, listings of prescription medications that are preferred for use by the managed behavioral healthcare organization, allow insurers to offer patients greater availability, access, and affordability of prescription drugs. When it is established that there is a medically necessary reason for the prescription of a non-formulary alternative, those MBHOs that manage prescription benefits will provide a clinically-based adjudication system to review those requests. Those who do not manage the prescription benefit will encourage the health plans with which they work to provide a clinically-based adjudication system to review those requests.

Background: Prevention initiatives are critical to the health and well being of our society. AMBHA member companies recognize the value of prevention activities. Educating consumers, providers, and purchasers about behavioral healthcare issues will facilitate the development of healthier communities.

Note: AMBHA uses terms "patient," "consumers," and "members" interchangeably.
April 29,1999