CALIFORNIA - Pacificare Health Systems

information about our Participating Providers. This
includes a QUALITY INDEX ® for helping you become
familiar with our Participating Providers. If you need a
copy or would like assistance picking you Participating
Provider, please call our Customer Service Department.
Your can also find an online version of the PBHC
Participating Provider Directory at www.pbhi.com.
What if I want to change my Participating
Provider?
Simply call the PBHC Customer Service toll-free
number at 1-800-999-9585 to select another PBHC
Participating Provider.
If I see a Provider who is not part of PBHC’s
Provider Network, will it cost me more?
Yes. If you are enrolled in this PBHC Behavioral Health
Plan and choose to see a provider who is not part of
the PBHC network, the services will be excluded, and
you will have to pay for the entire cost of the treatment
(except in an Emergency) with no reimbursement from
PBHC.
Can I call PBHC in the Evening or on
Weekends?
Yes. If you need services after normal business hours,
please call PBHC’s Customer Service Department at
1-800-999-9585. For the hearing and speech impaired,
use 1-888-877-5378 (TDHI). A staff member is always
there to help.
Continuity of Care With a Terminated Provider
In the event your Participating Provider is no longer
a part of the PBHC provider network for reasons
other than a medical disciplinary cause, fraud or
other criminal activity, you may be eligible to continue
receiving care from that provider following the
termination as long as the terminated provider agrees
to continue providing services under the terms and
conditions of the contract they had with PBHC at the
time their contract ended. Continued care from the
terminated provider may be authorized up to ninety
(90) days or longer if Medically Necessary for chronic,
serious or acute conditions, if you are receiving
Behavioral Health Services and are in a crisis period,
or until your care can be safely transferred to another
PBHC Participating Provider.
How Your Behavioral
Health Care Benefits Work
If you have any questions about this provision or
would like a copy of our Continuity of Care Policy, you
may call our Customer Service Department.
Continuity of Care With a Terminated Provider
In the event your Participating Provider is no longer a
part of the PBHC provider network for reasons other
than breach of contract, a medical disciplinary cause,
fraud or other criminal activity, you may be eligible to
continue receiving care from that provider to ensure
a smooth transition to a new Participating Provider
and to complete a course of treatment with the same
terminated Provider.
For a Member to continue receiving care from a
terminated Provider, the following conditions must be
met:
1. Continuity of Care services from a terminated
Provider must be Preauthorized by PBHC;
2. The requested treatment must be a Covered
Service under this Plan;
3. The terminated Provider must agree in writing
to be subject to the same contractual terms and
conditions that were imposed upon the Provider
prior to termination, including but not limited
to, credentialing, hospital privileging, utilization
review, peer review and quality assurance
requirements, notwithstanding the provisions
outlined in the provider contract related to
Continuity of Care;
4. The terminated Provider must agree in writing to
be compensated at rates and methods of payment
similar to those used by PBHC for current
Participating Providers providing similar services
who are practicing in the same or a similar
geographic area as the terminated Provider.
Covered Services for the Continuity of Care Condition
under treatment by the Terminated or Non-
Participating Mental Health Provider will be considered
complete, when:
i. the member’s Continuity of Care Condition
under treatment is medically stable, and
ii. there are no clinical contraindications that would
prevent a medically safe transfer to a Participating
Mental Health Provider as determined by a PBHC
Medical Director (or designee) in consultation
with the member, the Terminated Mental Health
Questions? Call the Customer Service Department at 1-800-624-8822. 59
PART A