Our clinical philosophy is to provide
the most appropriate member/practitioner match
and the least restrictive treatment intervention for each
member's needs across the life cycle. Our clinical orientation is a
biopsychosocial approach with emphasis on
wellness, early intervention, and integration
of behavioral and medical healthcare. Excellent
outcomes are maximized by good partnerships and a clinical consultation
approach with all clinicians that deliver services to our members.
Psychcare makes decisions whether to
approve or not approve payment for
services based only on the appropriateness of the care
or service, and what the member’s benefit plan covers.
The Medical Director oversees all triage and referral decisions. The Medical
Director is available 24 hours per day; 7 days per week, to consult on initial
clinical review decisions, and conduct peer clinical review.
The Vice President of Clinical Operations supervises nonurgent pre-service
processes, and initial clinical review processes. The Vice President of
Clinical Operations is available 24 hours per day, 7 days per week, to consult
with Case Managers on initial clinical review decisions
Emergency Referrals
In the event a patient is experiencing a behavioral health emergency in your
office, or contacts you in crisis, call the police. If your patient can be
safely transported with support, route the member to the nearest emergency
room. After ensuring that the patient is safe, call Psychcare 24 hours per day,
7 days a week at (800) 221-5487 so that we can obtain the clinical information
and begin managing the case.
If you call after hours or on the weekend, please inform the answering service
that you have an emergency and the on-call case manager, a licensed clinician,
will return your call within 30 minutes of the initial call. The on-call case
manager arranges hospital admissions, crisis stabilization, and other required
emergency services.
Initial Referral Process
Psychcare preauthorizes, and coordinates initial evaluations with our network
psychiatrists and clinicians.
During the course of your patients’
medical treatment, you may determine that
the patient could benefit from accessing their
behavioral healthcare benefits when, for instance:
** the member requires an assessment of their current psychotropic
medication(s), or an evaluation to determine the need for psychotropic
medication
** the member is experiencing an acute crisis and needs to be evaluated by a
psychiatrist
** the member is experiencing stressors that could possibly be reduced through
psychotherapy
When callers request routine outpatient
referrals, the calls are handled by
our intake coordinators. The intake coordinator
verifies the member’s eligibility and demographic information. They conduct a
brief screening using an approved screening tool.
During the screening, if, as indicated
per the screening tool, the call
requires clinical expertise, the intake coordinator transfers the call to
a case manager. Once the intake coordinator completes the
screening, the member is given the
names of network practitioners who meet
their geographic, language, and cultural preferences. The
member selects the practitioner they wish to see and the intake coordinator
authorizes the members’ outpatient visit.
If you would like refer a patient to Psychcare for mental health or substance
abuse treatment, simply fax a referral to Psychcare to
(800) 370-1116, or call us to
coordinate the referral at (800) 221-5487
during business hours, Monday through Friday
8:30 AM to 5:30 PM EST. Please
include all pertinent clinical information
and member contact information.
Continued Treatment
All urgent care and continued treatment
are reviewed by case managers. Case
Managers are, at a minimum, Masters’ Level
Licensed Clinicians, or Registered Nurses,
with a minimum of 5 years experience
post master and/or previous experience in providing direct patient care,
crisis intervention and discharge planning. The case managers
review the continued treatment at
pre-determined intervals with the psychiatrist,
clinician, hospital, or program. Ongoing
authorization is based on, as applicable
to the individual status of the
member, Psychcare
Mental Health Level of Care Clinical
Criteria, Psychcare Substance Abuse Level
of Care Criteria or Florida Medicaid Level of Care
Guidelines and the member’s benefit coverage.
In particular, cases, care may be required outside of the usual parameters set
forth by the member’s benefit plan. In such cases, the Medical Director and the
Vice President of Clinical Operations may work with the case manager and the
practitioner to develop an appropriate treatment care plan.
Specialized Services Requirements
The following services are authorized only when they are determined to be
medically necessary, and inclusive in the member’s benefit coverage. The case
manager consults with the Medical Director when the following services are
requested, and covered under the member’s benefit plan:
** psychological testing
** electroconvulsive therapy (ECT)
The following services are typically not covered under a typical benefit plan:
** marital counseling
** testing for educational placement
** neuropsychological testing
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