PSYCHCARE TRIAGE AND REFERRAL PROCESSES


Our  clinical  philosophy  is  to  provide  the  most  appropriate  member/practitioner  match  and  the  least  restrictive treatment intervention for each member's needs across the life cycle. Our clinical orientation is a biopsychosocial approach  with  emphasis  on  wellness,  early  intervention,  and  integration  of  behavioral  and  medical  healthcare. Excellent outcomes are maximized by good partnerships and a clinical consultation approach with all clinicians that deliver services to our members.

Psychcare  makes  decisions  whether  to  approve  or  not  approve  payment  for  services  based  only  on  the appropriateness of the care or service, and what the member’s benefit plan covers. 

The Medical Director oversees all triage and referral decisions. The Medical Director is available 24 hours per day; 7 days per week, to consult on initial clinical review decisions, and conduct peer clinical review. 

The Vice President of Clinical Operations supervises nonurgent pre-service processes, and initial clinical review processes. The Vice President of Clinical Operations is available 24 hours per day, 7 days per week, to consult with Case Managers on initial clinical review decisions 


Emergency Referrals

In the event a patient is experiencing a behavioral health emergency in your office, or contacts you in crisis, call the police. If your patient can be safely transported with support, route the member to the nearest emergency room. After ensuring that the patient is safe, call Psychcare 24 hours per day, 7 days a week at (800) 221-5487 so that we can obtain the clinical information and begin managing the case. 

If you call after hours or on the weekend, please inform the answering service that you have an emergency and the on-call case manager, a licensed clinician, will return your call within 30 minutes of the initial call. The on-call case manager arranges hospital admissions, crisis stabilization, and other required emergency services.

Initial Referral Process

Psychcare preauthorizes, and coordinates initial evaluations with our network psychiatrists and clinicians. 

During  the  course  of  your  patients’  medical  treatment,  you  may  determine  that  the  patient  could  benefit  from accessing their behavioral healthcare benefits when, for instance:

** the member requires an assessment of their current psychotropic medication(s), or an evaluation to determine the need for psychotropic medication  
** the member is experiencing an acute crisis and needs to be evaluated by a psychiatrist
** the member is experiencing stressors that could possibly be reduced through psychotherapy

When  callers  request  routine  outpatient  referrals,  the  calls  are  handled  by  our  intake  coordinators.  The  intake coordinator verifies the member’s eligibility and demographic information. They conduct a brief screening using an approved  screening  tool.  During  the  screening,  if,  as  indicated  per  the  screening  tool,  the  call  requires  clinical expertise, the intake coordinator transfers the call to a case manager. Once the intake coordinator completes the
screening,  the  member  is  given  the  names  of  network  practitioners  who  meet  their  geographic,  language,  and cultural preferences. The member selects the practitioner they wish to see and the intake coordinator authorizes the members’ outpatient visit. 

If you would like refer a patient to Psychcare for mental health or substance abuse treatment, simply fax a referral to  Psychcare  to  (800)  370-1116,  or  call  us  to  coordinate  the  referral  at  (800)  221-5487  during  business  hours, Monday  through  Friday  8:30  AM  to  5:30  PM  EST.  Please  include  all  pertinent  clinical  information  and  member contact information. 

Continued Treatment

All  urgent  care  and  continued  treatment  are  reviewed  by  case  managers.  Case  Managers  are,  at  a  minimum, Masters’  Level  Licensed  Clinicians,  or  Registered  Nurses,  with  a  minimum  of  5  years  experience  post  master and/or previous experience in providing direct patient care, crisis intervention and discharge planning. The case managers  review  the  continued  treatment  at  pre-determined  intervals  with  the  psychiatrist,  clinician,  hospital,  or program.  Ongoing  authorization  is  based  on,  as  applicable  to  the  individual  status  of  the  member,  Psychcare
Mental  Health  Level  of  Care  Clinical  Criteria,  Psychcare  Substance  Abuse  Level  of  Care  Criteria  or  Florida Medicaid Level of Care Guidelines and the member’s benefit coverage.

In particular, cases, care may be required outside of the usual parameters set forth by the member’s benefit plan. In such cases, the Medical Director and the Vice President of Clinical Operations may work with the case manager and the practitioner to develop an appropriate treatment care plan.

Specialized Services Requirements 

The following services are authorized only when they are determined to be medically necessary, and inclusive in the member’s benefit coverage. The case manager consults with the Medical Director when the following services are requested, and covered under the member’s benefit plan:

** psychological testing
** electroconvulsive therapy (ECT) 

The following services are typically not covered under a typical benefit plan:

** marital counseling
** testing for educational placement
** neuropsychological testing  

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