2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

Care CoordinationSpecialists as PCPs for Members with SpecialHealth Care NeedsOn an individual basis, specialists treatingmembers with disabilities or chronic/complexconditions may serve in the capacity of PCP. Thespecialist is credentialed as a PCP/Specialist andperforms all PCP duties within the scope of theparticipating specialist’s certification.Contact your provider network managementrelationship executive listed in the Provider NetworkRelations Contact Guide athttp://docs.phs.org/idc/groups/public/%40phs/%40php/documents/phscontent/pel_00140718.pdf.Behavioral Health Care CoordinationMembers may access the Behavioral Healthnetwork of contracted providers without a referral orprior authorization. They do not need a referral formost outpatient services. Behavioral HealthServices for Centennial Care members areadministered through Magellan. For assistance infinding behavioral health providers, you or yourpatients may contact the following:For Commercial, Presbyterian Senior Care (HMO)and MediCare PPO members: 505-923-5221 or 1-866-593-7431.For Centennial Care members: 505-923-8858 or 1-866-672-1242.Presbyterian encourages PCPs and behavioralhealth practitioners to communicate with oneanother regarding individual cases.Members may access Centennial Care contractedbehavioral health providers without a referral orprior authorization. Referrals are not needed formost outpatient services.For Presbyterian Centennial Care patients, theprovider can make a direct referral for BehavioralServices based on the following indicators:1. Suicidal/homicidal ideation or behavior;2. At-risk of hospitalization due to a BehavioralHealth condition;3. Children or adolescents at imminent riskof out-of-home placement in a psychiatricacute care hospital or residential treatmentfacility;4. Trauma victims;5. Serious threat of physical or sexual abuseor risk to life or health due to impairedmental status and judgment, mentalretardation, or other developmentaldisabilities;6. Request by Member or Representative forBehavioral Health services;7. Clinical status that suggests the need forBehavioral Health services;8. Identified psychosocial stressors andprecipitants;9. Treatment compliance complicated bybehavioral characteristics;10. Behavioral and psychiatric factorsinfluencing medical condition;11. Victims or perpetrators of Abuse and/orneglect and Members suspected of beingsubject to Abuse and/or neglect;12. Non-medical management of substanceabuse;13. Follow-up to medical detoxification;6-192014 Practitioner and Provider Manual - Ver. 3