EMERGENCY AND URGENT CARE AUTHORIZATION PROCEDURES
A mental health or substance abuse emergency represents a life-threatening situation. In the Carelon Provider Agreements, we define “emergency” to mean the sudden onset of a mental health or substance abuse condition manifesting itself by acute symptoms and one or more of the following circumstances are met:
- The patient is in imminent or potential danger of harming himself or others as a result of a condition included as a Covered Service.
- The patient shows symptoms (e.g., hallucinations, agitation, delusions, etc) resulting in impairment in judgment, functioning, and/or impulse control severe enough to endanger his or her own welfare or that of another person.
- There is an immediate need for Covered Services as a result of or in conjunction with a very serious situation, such as an overdose, detoxification, or potential suicide.
Carelon may not deny payment for treatment obtained when a representative of Carelon instructs the member to seek emergency services.
The entities specified in 42 CFR 438.114(b) may not limit what constitutes an emergency behavioral health condition on the basis of lists of diagnoses or symptoms.
Carelon may not deny payment for treatment obtained when a member had an emergency behavioral health condition, including cases in which the absence of immediate behavioral health attention would not have had the outcomes specified in 42 CFR 438.114(a) of the definition of emergency medical condition.
Carelon may not refuse to cover emergency services based on the emergency room provider, hospital, or fiscal agent not notifying Carelon of the member’s screening and treatment within 10 calendar days of presentation for emergency services.
The attending emergency physician, or the provider actually treating the member, is responsible for determining when the member is sufficiently stabilized for transfer or discharge, and that determination is binding on the entities identified in 42 CFR 438.114(b) as responsible for coverage and payment.
A member who has an emergency behavioral health condition may not be held liable for payment of subsequent screening and treatment needed to diagnose the specific condition or stabilize the patient.
After the member is seen and the emergency is resolved, the Service Manager will revert to the routine policies and procedures for authorization, continued certification, and post-stabilization care services.
Please Note, for Payment Purposes: Emergency Room (ER) visits by HealthChoices members presenting with a primary behavioral health diagnosis that do not result in an inpatient admission are the responsibility of the PH-MCO.
Post Stabilization Care Services
Once a member has been stabilized, the provider shall be responsible for obtaining necessary preauthorization for continued treatment of a member.
For continued stay requests, providers must follow the inpatient concurrent review process outlined below.
Carelon requires providers to request preauthorization by calling our Engagement Center’s toll-free provider number (877-615-8503) for the admission of eligible members into all levels of care except for outpatient services. In emergency situations (i.e., those which require immediate care and treatment to avoid jeopardy to the life or health of the individual or harm to another person by the individual), authorization must be requested on the same day. Please note that the Carelon Engagement Center is staffed by clinical Service Managers for the receipt of preauthorization requests, referrals, and concurrent reviews 24 hours per day, 7 days a week. Authorization letters may be obtained through our online ProviderConnect system. To access ProviderConnect, visit pa.carelon.com/providers. To obtain a User ID, click on register, complete the required form, and click on submit.
All requests for authorization of continued stays must be made on the last covered day. The Engagement Center is staffed with Service Managers 24 hours per day, 7 days a week. The Service Manager conducting the initial authorization will provide specific instructions for concurrent review procedures.