1) The member calls PacifiCare Behavioral Health directly at the designated (800) number.
2) The clinical services representative gathers basic demographic information, verifies eligibility and determines the type of services the member is seeking.
3) The clinical services representative conducts a brief assessment. The member is asked about:
Severity of the problem/symptoms
How the problem may be affecting aspects of the member's life
How the problem relates to past experiences
4) The PBH clinical services representative matches the member with an appropriate group practice or individual provider based on the member's needs, geographic location and the Medical Necessity of the situation.
5) The member is referred to a PBH network provider, who is authorized for a specific number of visits over a specified period of time.
6) PBH notifies the provider by telephone of the referral and services authorized, and an authorization form is subsequently mailed to the provider.
Remember This About PBH Referrals
All services (including psychological testing) must be pre-authorized. Services will not be reviewed retroactively. Make sure your members have contacted PBH prior to your appointment.
Once the initial referral has been made, it is the provider's responsibility to obtain further authorization.
Pre-Authorization = Claims paid (according to benefit limitations and exclusions)
Failure to pre-authorize service = Denial of claim
All services are to be provided by the PacifiCare Behavioral Health credentialed/contracted provider named on the authorization.
If you have not received a telephone call notifying you of a referral, contact the PBH Helpline listed in the Quick Reference Guide for verification of referral.
Primary care physicians may contact PBH to make a referral for one of their members.
Written authorization forms will arrive within one week of referral. Contact PBH if you have not received your authorization.
