PBHC uses criteria or guidelines based on Medical Necessity
to determine whether to approve, modify, deny or delay Behavioral
Health Services to its members. The criteria used in the member's
specific case will be disclosed to you and to the members.
The decision to approve, modify, deny or delay Behavioral
Health Services are made within the following timeframes,
as required by California State Law:
Decisions based on Medical Necessity will be made in
a timely fashion appropriate for the nature of the member's
condition, not to exceed five (5) business days from receipt
of information reasonably necessary to make the decision.
If the member's condition poses an imminent and serious
threat to their health, including, but not limited to, potential
loss of life, limb, or other major bodily function, or lack
of timeliness would be detrimental in regaining maximum
function, the decision will be made in a timely fashion
appropriate for the nature of the condition, not to exceed
seventy-two (72) hours after receipt of the information
reasonably necessary and requested by PBH to make the determination.
PBH will notify requesting participating providers of
the decision to approve, modify or deny requests for authorization
within twenty-four (24) hours of the decision. Members are
notified, in writing, within two (2) business days of the
decision.
