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Mental and Nervous Services Provided by a Primary Care Physician

EPS Exclusive Groups (EPX)
Benefit plans for some groups require that mental and nervous and substance abuse services be rendered exclusively by a provider in the Expanded Psychiatric Services Network (EPS). Blue Cross and Blue Shield of Alabama holds a contract with Alabama Psychiatric Services (APS) for the provision of these services. Members must see an EPS network provider in order to receive benefits. Services provided by an out-of-network provider will not be covered.

No referral is required when members receive services from an EPS provider.

For EPS exclusive (EPX) groups, services with mental and nervous diagnoses may be provided to Personal Choice members by their Primary Care Physician (PCP). The PCP may also provide services for Attention Deficit Disorder (ADD).

PCPs may file for office visits but will not be reimbursed for psychotherapy services. The usual office visit copayment will apply.

For benefits to be received for mental and nervous services not provided by the PCP, the PCP must refer the member to an EPS provider. If the member requires hospitalization, the PCP must refer the patient to an EPS provider. PCPs may not directly refer a member for inpatient mental and nervous services.

EPS Non-Exclusive Groups (EPS)
Members with the EPS non-exclusive benefit may receive services from an EPS network provider. They may also elect to see a covered provider (most contracts cover psychiatrists or psychologists) who is not in the EPS network. Members receive maximum benefits when services are rendered by an EPS network provider. Services rendered by an out-of-network provider will be subject to applicable deductibles, copayments and contract maximums.

No referral is required when members receive services from an EPS provider. A referral is required when members receive services from an out-of-network provider.

Payments to the PCP will be at the group’s current level of benefits for mental and nervous services. If the group has carved out mental and nervous benefits to another carrier, no payment will be made by Blue Cross and Blue Shield of Alabama.

Last Updated March 2010