Issued and entered December 19, 2002 by Frank M. Fitzgerald, Commissioner

ORDER

I
PROCEDURAL BACKGROUND

On August 28, 2002, XXXXXXXXXX (Petitioner) filed a request for external review with the Commissioner of Financial and Insurance Services (Commissioner) under the Patient's Right to Independent Review Act (PRIRA), MCL 550.1901 et seq. After a review of the material submitted the Commissioner accepted the request on September 5, 2002.

The issue involved in the adverse determination is contractual. The Commissioner reviews contractual issues pursuant to MCL 550.1911(7). As a result, review by an independent review organization is not required. The Commissioner notified Blue Cross and Blue Shield of Michigan (BCBSM) of the request for external review and requested the information it used in its adverse determination. The Office of Financial and Insurance Services received the BCBSM information on September 16, 2002.

II
FACTUAL BACKGROUND

From XXXXXXXXXX through XXXXXXXX, Petitioner received outpatient mental health care from XXXXXXXXXXXXXX, a licensed social worker. The total charge in question is $1,200.

BCBSM denied payment for the mental health care since it was not provided by a physician, a fully licensed psychologist, or a staff member of a participating outpatient mental health clinic. Petitioner claims her mental health care is a covered benefit and BCBSM is required to pay for it.

III
ISSUE

Whether BCBSM properly denied coverage for mental health care provided to Petitioner by a licensed social worker?

IV
ANALYSIS

Petitioner's Position

Petitioner began seeing XXXXXXXXX, a licensed social worker, after she and her husband separated in XXXXXXXXXXXX. Petitioner's husband was terminated from his job in XXXXXXXX which caused Petitioner to switch health insurers. Petitioner's former health insurer paid for Petitioner's therapy from XXXXXXX.

Petitioner's new heath care carrier, BCBSM, rejected Petitioner's claims for XXXXXXX therapy on the basis that XXXXXXXX not a M.D., D.O or licensed psychologist. Petitioner claims that this is irrelevant. Petitioner claims that therapy provided by someone other than a M.D. or D.O. can be very effective. She argues what is important is continuity of care. Petitioner claims that switching to a new therapist would be a major disruption in her care, since XXXXXXXX has been involved in petitioner's care from the beginning.

Petitioner indicates that XXXXXX has informed her that she receives payment from BCBSM for patients that have coverage through certain groups. Petitioner therefore argues that BCBSM should pay for her care.

BCBSM's Position

Petitioner has health care coverage through XXXXXXXXXXXXX Company, an industry rated group. The coverage is governed by the terms of the Community Blue Group Benefits Certificate. Section 7 of the Certificate defines terms used in the Certificate as follows:

Physician

Doctors of Medicine, Osteopathy, Podiatry, Chiropractic and Dentistry.

Psychologist

A practitioner of clinical psychology, counseling or guidance, who is fully licensed and certified by the state of Michigan or by the state where you receive services. Where there are no certification or licensure requirements, the psychologist must be recognized by the appropriate society.

The Certificate provision granting coverage is entitled, "Outpatient Mental Health Care." It states:

We pay for the following outpatient mental health services when provided by a physician or fully licensed psychologist in a physician's office or in a participating outpatient mental health facility, unless otherwise specified.

BCBSM states that XXXXXXX is not a physician or psychologist as defined in the Certificate. BCBSM also states that XXXXX is an individual provider and is not part of a participating outpatient facility. Therefore, BCBSM claims that care provided by XXXXXXXXX is not a covered benefit and thus BCBSM is not required to pay for it.

Commissioner's Review

The Certificate of coverage controls the analysis of this matter. The Certificate indicates that outpatient mental health is payable only when provided by a physician or fully licensed psychologist in a physician's office or in a participating outpatient mental health facility. BCBSM established that Petitioner's outpatient mental health care was provided by a social worker. Therefore, the Commissioner concludes this care is not a covered benefit and BCBSM is not required to pay for it. The fact the Petitioner's former health care coverage paid for her care does not alter the conclusion that this care is not a covered benefit under her BCBSM Certificate.

Petitioner argued that BCBSM has paid for care provided by her therapist for other patients who have coverage through other BCBSM groups. Some BCBSM groups cover outpatient mental health care provided by limited licensed physiologists and licensed social workers. Petitioner's coverage does not include such a benefit.

V
ORDER

Therefore, the Commissioner ORDERS that the final adverse determination by BCBSM dated August 20, 2002 is upheld. BCBSM is not required to pay for the Petitioner's outpatient mental health care provided by XXXXXXXXXXXXXXX.

This is a final decision of an administrative agency. Under MCL 550.1915, any person aggrieved by the Order may seek judicial review no later than sixty days from the date of this Order in the Circuit Court for the country where the covered person resides or in the Circuit County of Ingham County. A copy of the petition for judicial review should be sent to the Commissioner of the Office of the Office of Financial and Insurance Services, Health Plans Division, Post Office Box 30220, Lansing MI 48909-7720.