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:
- 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)
Aetna Better Health
Gateway Health Plan
UnitedHealthcare Community Plan
UPMC for You
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.