Provider Manual

COORDINATION OF CARE

The Pennsylvania Department of Human Services requires significant cooperation and coordination of care between the behavioral health provider and the primary care physician (PCP) to achieve optimal health for each member and in adherence to all applicable state and federal regulations. Providers should contact the member’s PCP or physical health plan’s Special Needs Unit (SNU) for specialty referral or authorization required for covered physical health services.

Carelon requires that providers adequately assess all individuals to ensure that appropriate referrals are made when necessary. Providers should have a comprehensive list of referral resources to provide members as needed, along with guidance to provide the Carelon telephone numbers for members to directly request referrals from the BH-MCO as necessary.

Providers must also ensure that all individuals providing treatment to a member should coordinate to create a consistent treatment plan driven by the member. Providers should seek consultation from other professionals as needed to provide the best care to a member when treatment challenges emerge. Providers are also expected to participate fully in all interagency meetings regarding a member in their care and should ensure a representative is present to support the coordination of care of the member.

In addition, Carelon providers are expected to consult with the PCP, where appropriate, to exchange clinical information and coordinate pharmacy services as noted in the points below:

  1. The provider should obtain the member’s consent to release information to the member’s PCP or documentation of the member’s declination. Providers should supply written notification of diagnostic/treatment services to the PCP and inform the PCP of any prescription for medication. The provider must supply written notification of any changes in the member’s medication to the PCP. A copy of the written notification to the PCP should be placed in the patient record. In the event of an emergency, or in any case in which immediate notification is important to the member’s health, the PH-MCO provider shall be notified by telephone and will be encouraged to send a confirmation in writing to the BH-MCO provider via facsimile or US mail.
  2. In the event that the member refuses to sign a release of information, the provider must document in the patient record all attempts to follow-up and obtain a release of information.
  3. Carelon conducts Quality Management record audits to ensure that releases are present in the patient record and notifications to PCPs (as described herein) have taken place.
  4. Providers must ensure that they interact with, and coordinate services with, the Physical Health Service Systems (PHSS) and their Primary Care Physicians (PCPs). Both behavioral health clinicians and PCPs have the obligation to coordinate care of mutual patients. Consistent with state and federal confidentiality laws and regulations, both must:
    1. Ascertain the Member’s PCP, and/or relevant physical health specialist, or behavioral health clinician and obtain applicable releases to share clinical information.
    2. Make referrals for social, vocational, education, or human services when a need for such service is identified through assessment.
    3. Provide health records to each other, as requested.
    4. Assure coordination between behavioral and physical health care, including resolution of any clinical dispute.
    5. Be available to each other for consultation.
  5. The physical health plans maintain a formulary for medications. Changes to the formulary are communicated to the Carelon physician network thirty (30) days prior to the effective date.
  6. All pharmacy services, with the exception of methadone for opiate treatment, are the payment responsibility of the physical health MCO. An MCO may require prior authorization as a condition of coverage or payment for an outpatient prescription drug.

For questions about coverage or payment for pharmacy services, the appropriate MCO should be contacted directly. Links to formularies are on the Carelon Member Contacts Page

AmeriHealth Caritas (for Crawford, Mercer and Venango County Members)
1-888-991-7200
www.amerihealthcaritaspa.com

Aetna Better Health
1-866-638-1232
www.aetnabetterhealth.com/pennsylvania

Gateway Health Plan
1-800-392-1147
www.gatewayhealthplan.com

UnitedHealthcare Community Plan
1-800-414-9025
www.uhccommunityplan.com

UPMC for You
1-800-286-4242
www.upmchealthplan.com

Payment for the provision of ambulance services under HealthChoices is the responsibility of the PH-MCO. Per 55 Pa. Code 1245.52, the PH-MCO is financially responsible for all emergency ambulance transportation for both physical and behavioral health services. Carelon may coordinate emergency transportation with the PH-MCO as appropriate. No pre-authorization is required for emergency transportation.

In addition to emergency transportation, each county provides routine transportation through the Medical Assistance Transportation Program (MATP). This includes transportation to a doctor, dentist, pharmacy, and mental health or drug and alcohol treatment program. To arrange transportation services, please call the designated county MATP number listed on the Carelon’s Medical Assistance Transportation Program Information. Please refer to this web page for more information about the program, as well.