2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

Behavioral HealthAn initial PCP contact or routine physicalexamination indicating a substance abuseproblemA prenatal visit indicating substance abuseproblemsPositive response to questions indicatingsubstance abuse problemsObservation of clinical indicators or laboratoryvalues indicating substance abuse problemsA pattern of inappropriate use of medical,surgical, trauma, or emergency room servicesthat could be related to substance abuseproblems or other behavioral health conditionsThe persistence of serious functionalimpairmentWhen a member is involved or at risk of becominginvolved with the CYFD, it is an indicator of thepossible need for more intensive care coordinationactivities. Providers should be prepared toparticipate in care coordination and CYFDprotocols, staffing, discharge planning, or otherrequirements.Children in tribal custody or under tribal supervisionpursuant to a Tribal Court order (as such term isdefined in New Mexico Statutes Annotated [NMSA]1978 § 32A-1-4) must receive a behavioral healthscreening within 24 hours of a referral to abehavioral health contract provider and receive abehavioral health assessment, any medicallynecessary covered services, and care coordinationas appropriate.Member ReferralsMembers may refer themselves to providers ofcovered services without contacting Presbyterian orobtaining a referral from their PCP. Regardless ofwhether the member is self-referred, referred byPresbyterian, or referred by a PCP, providers arerequired to authorize services in accordance withPresbyterian’s requirements in the PriorAuthorization section of this chapter.After-Hours Coverage for Member EmergenciesBehavioral health providers must have or arrangefor on-call and after-hours coverage to supportmembers who are experiencing behavioral healthcrises or emergencies. Such coverage must beavailable 24 hours a day, seven days a week.Providers must inform members about hours ofoperation and provide instruction for contacting oncallstaff after hours. When unavailable to provideon-call support, providers must arrange foralternative coverage with another participatingclinician.Crisis/Emergency Room UsagePresbyterian strives to provide the appropriatebehavioral health services in a timely manner for allmembers. For members requiring intervention froma crisis or an emergency room service provider,coordination with the member’s care coordinator isrequired. The care coordinator can assist withidentifying and referring the member to theappropriate level of care.9-82014 Practitioner and Provider Manual - Ver. 3