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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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Medical billing basics,
Psychology billing
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