PBH adheres to the following definitions related to emergency
services:
Emergency condition is a mental disorder or substance
use disorder manifesting itself by acute symptoms of sufficient
severity, including pain, such that the absence of immediate
behavioral health services could reasonably be expected
to result in any of the following:
Immediate harm to self or others
Serious and permanent dysfunction to the member
Serious impairment of the member's functioning
Placing the member's health in serious jeopardy
Urgent and emergent services are also covered without
prior authorization in cases where a prudent layperson,
acting reasonably, would have believed that an urgent or
emergency medical condition existed.
Examples of an emergency include:
A PBH member who is in imminent danger of suicide,
as evidenced by a clearly defined plan and history of
suicide attempts requiring medical or psychiatric treatment
A PBH member who threatens to seriously injure a
named or clearly designated person within a specified
period of time
Emergency treatment is the immediate and unscheduled behavioral
health screening, examination and evaluation of a member
by a physician to determine if an Emergency Condition exists
and, if it does, the care and treatment necessary to relieve
or eliminate the emergency condition.
Emergency admission is medically necessary behavioral
health services which are immediately required because the
member is experiencing a severe level of symptoms according
to a DSM-IV diagnosis and is impaired in his or her functioning
to the extent that he or she presents an immediate danger
of harm to self or others.
A member requiring emergency services usually comes to the
attention of PBH in one of the following ways:
The member contacts PBH, and in the course of the assessment
the patient evidences need for emergency intensive services
A facility contacts PBH and requests emergency services
A PBH provider requests a step up to emergency services
from a lower level of care (e.g. routine outpatient services)
The member's PCP has identified symptoms or behaviors
requiring an emergency assessment
