The PBH clinical services staff member calls the provider
to inform him or her of the referral. The provider is given
the following information about the member being referred:
Name and authorization number
The member's benefit structure
Urgency of the referral or anything unique to the member's
request for services
A written authorization is mailed to the provider
Under certain circumstances the nature of a problem may
be such that the PBH clinical services staff requests that
the member be seen on the same or next day. If not identified
as an urgent or emergent case, the member must be seen within
ten business days.
If the case is urgent or emergent, the provider is expected
to call the PBH clinical staff person immediately following
the first appointment with information about the proposed
treatment strategy for the member.
If the member does not show up for the first urgent or
emergent appointment, the provider should report this immediately
to PBH staff. It is not necessary for the provider to return
the authorization form to PBH for the patient in this situation.
On occasion, a PBH member may call a network provider directly
prior to receiving an authorization for treatment. In such
cases, the provider should instruct the patient to call our
toll-free member number (available in the Quick
Reference Guide in the Region Specific Information section
of this manual) to request authorization and referral instructions
directly from PBH.
On occasion, a PBH member may call a network provider immediately
after their telephone assessment to schedule an appointment.
In these situations the provider will not yet have received
phone notification or written verification from PBH. The provider
is encouraged to schedule the appointment and confirm the
authorization by telephone by calling the Provider Helpline
at (800) 716-1166.
Remember
A member must call to initiate care
In the event a member is unable to complete the assessment
due to emergency or grave disability, a facility representative,
Primary Care Physician (PCP), Employee Assistance Program
(EAP) counselor, family member or provider can call for
a referral/authorization for that member.
All services except emergencies and urgently needed care
must be pre-authorized. Services will not be reviewed retrospectively.
Make sure the member has contacted PBH before you see them
for an appointment.
The telephone assessment is intended to provide the member
with quality care by making timely referrals to the appropriate
provider and level of care.
