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| How does a provider enroll in the PBH network? |
| A prospective Provider should contact the Provider Network Administrative Coordinator at 704-721-7011, or 1-800-958-5596 or email the Provider Network Administrative Coordinator to request an application for either an Agency or Licensed Independent Practitioner. |
| What is a Licensed Independent Practitioner? |
| This includes Medical Doctors (M.D.), Practicing Psychologist (Ph.D), Psychologist Associates (Master’s Level Psychologist (LPA), Master’s Level Social Worker (LCSW), Licensed Marriage and Family Therapists (LMFT), Licensed Professional Counselors (LPC), Licensed Nurse Practitioners, Licensed Physician Assistants, Certified Substance Abuse Counselors or a member of the Provider Network who bills under their own license. |
| How do you define “Agency”? |
| An agency is an Area Facility as defined by 122C-3 subsection 14A. An agency may deliver a number of services, submits, and bills claims under a tax ID number. |
| Who do I call in Network Provider Relations to get information? |
Cynthia Benjamin – Area Provider Relations Manager 704-721-7071 Chuck Hill – Data Support & Decision Making Coordinator 704-721-7050 |
| What are the types of enrollments that agencies or individuals may pursue to be part of the PBH network? |
| We have two types of of enrollment. One is for Licensed Independent Practitioners and one for Agencies. Either applications may be obtained by calling Provider Network Administrative Coordinator at 704-721-7011. |
| Agency Enrollment Network Provider |
| Applications may only be submitted by Prospective Agencies and Independent Licensed Practitioners to provide consumer services located within the five (5) counties (Cabarrus, Davidson, Rowan, Stanly, and Union) in the PBH catchment area.
Out of Area Provider – In State Used when services are not available by a Network Provider in the PBH catchment area. The provider must complete an out of area application. The UM department and the Medical Director must certify that the following criteria is met:
Out of Area Provider – Out of State Services are not available in the PBH network or out of area –in state. The Provider must complete an out of area application and be willing to accept NC reimbursement. The UM Department and the Medical Director must certify that the following criteria is met:
Licensed Independent Practitioners -Network Provider Network Licensed Independent Practitioners are Credentialed into the PBH Network if they provide services in the five counties. Out of Area Provider – In State Licensed Independent Practitioners located outside of the five counties are credentialed as out of area – in state. Some consumers or families have historically gone to Licensed Independent Practitioners in Charlotte. Out of Area Provider – Out of State PBH does not contract with any Licensed Independent Practitioner outside of the State of NC unless a consumer has been placed in the State and services are medially required. |
| How are Licensed Independent Practitioners enrolled? |
| Licensed Independent Practitioners submit the PBH Uniform Healthcare Application and have all credentials reviewed. The application may be obtained by calling the Provider Network Administrative Coordinator at 704 721-7011. |
| What is involved in the credential process? |
If they are not available anyone else in the Department would be happy to provide information and the numbers are as follows: Cynthia Benjamin – DD Provider Relations Manager 704 721-7071 Chuck Hill – Adult MH Provider Relations Manager 704 721-7050 |
| I am seeing PBH consumers who have Medicaid and am not a network provider. What do I do? |
| Contact PBH Network Management ASAP at 1-800-958-5596 or 704-721-7011. You will either have to apply to enroll or work with PBH to transition your consumers if you are an out of network provider |
| Do all providers have to complete the Orientation Competencies? |
| Yes, they may be found online at www.pbhcare.org under the provider tab. The competencies are designed to ensure that each provider becomes informed about successfully doing business with the LME. |
| How long does it take to become enrolled? |
| For Agencies this can take up to 90 days after an application has been received. For Licensed Independent Practitioners the credentialing committee meets every two weeks and reviews completed packets at that time. The PBH’s Medical Director, Dr. Hummel, has the ability to grant temporary privileges under very specific circumstances. |
| I want my child to go to a specific agency outside of your area who is not contracted. Can PBH do that by tomorrow? |
| PBH would assess the current service providers who provide that service within our network and as out of area providers. Once the Medical Director and Utilization Management make a determination, a decision would be made on sending the Agency an application.
Note: There is an Emergency Enrollment Procedure, which does allow for the process to be pursued more quickly than the normal 90-days or less but it has very specific guidelines that must be met. |
| What are the guidelines to request an emergency enrollment? |
| The Medical Director and UM must certify that the consumer has immediate heath and safety issues. This is defined, as a failure to provide service within a reasonable time will potentially result in physical or psychological harm or injury to the consumer, their family, or others in the community, incarceration of the consumer, or homelessness. |
| What is an Out of Network Provider? |
| If a person has a provider who does not want to apply to the PBH network or meet PBH’S standard they are an out of network provider. |
| What if I am a consumer seeing an Out of Network provider? |
| The provider will be required to work out a transition plan to change you to a provider in the Network within sixty (60) days. If the person receives non-emergency services from an out of network provider, PBH will not pay for the service. PBH will pay for emergency behavioral healthcare for a PBH enrollee by an out of network provider. |
| How does PBH pay a provider during the transition period? |
You must complete:
Claims for services must be submitted to PBH by one of the following methods:
PBH offers Provider Direct training on a weekly basis, This can be scheduled by calling 704-721-7115. Claims must be submitted to PBH within ninety (90) days of the date of service. Claims submitted past ninety (90) days of the date of the service will be denied and cannot be resubmitted. The following people are important contacts that you should reach: Provider Network Administrative Coordinator - To provide data in the form of an abbreviated application. (704-721-7011) Finance – Customer Service (704-721-7038) Utilization Management – Pam Rankin (704-743-2107) for mental health & substance abuse services, or |
| Who do I work with to transition the consumer? |
| If the consumer has a PDS Support Coordinator, they should be your first contact. If they do not, then you or your Agency should contact PBH ACCESS at the following number: 1-800-939-5911. |
| What if I want to enroll, but have not started the process and, I am or my agency is providing treatment to PBH consumers? |
| You should contact PBH Network Management ASAP. The Provider Network Administrative Coordinator at 704-721-7011, if they are not available then you should ask to speak to another staff person. You will have to start the enrollment process and also have basic information entered into the system to allow payment of claims on a temporary basis until your application or credentials are reviewed. If your credentials or application were denied, then the services would have to be transitioned to a network provider |
| I am a consumer looking for services. Who can give me a list of Agencies in my area? |
| You will receive or should have received a Member Manual, including in that is a list of all Network Providers. In addition, the PDS Support Coordinator should be able to give you a list of contracted network providers. Many Agencies have web sites or brochures that they have given to PDS in your County.
You may also call the PBH ACCESS Center at 1-800-939-5911 and ask for the names of providers in your area. Also see our online downloads. |
| I don’t have any insurance and need outpatient behavioral healthcare services. How do I find out whom I might be able to see for treatment? |
| Please talk to your PDS Support Coordinator or call ACCESS at 1-800-939-5911.
The ACCESS Unit staff will be able to refer you to a Contract Provider such as Comprehensive Care Providers in the five counties who receive funds to work with people who do not have insurance. The provider will work with the PBH UM Department on an ongoing basis on your care needs Cabarrus - DAYMARK Recovery Services Davidson – DAYMARK Recovery Services Rowan - DAYMARK Recovery Services Stanly - DAYMARK Recovery Services Foundations Behavioral Healthcare Union DAYMARK Recovery Services Excel Personal Development |
| What happens if a consumer needs specialized services or has unique needs and does not have insurance or medicaid ? For instance, a consumer needs a clinician who speaks Spanish or treats a specialized disorder? |
| Not all agencies that provide specialized services are funded to work with clients who are not medicaid eligible or do not have insurance. It is important that consumers tell ACCESS their special needs so that they can review them and authorize services to the most appropriate provider on a case-by-case basis. |
| Where can I get more information about PBH? |
| www.pbhcare.org is an excellent resource for prospective providers, providers, and consumers. |
© 2007-2008 PBH
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