HOW TO OBTAIN AUTHORIZATION FOR MENTAL HEALTH SERVICES
Specialty mental health services offered by the San Francisco Mental Health Plan fall into three broad categories: planned services, which require prior- authorization by the SFMHP; urgent care services, which sometimes require prior-authorization; and emergency services, which do not require prior- authorization. This section of the Provider Manual describes the processes related to each of these service categories.
AUTHORIZATION FOR PLANNED SERVICES
All planned (non-emergency) mental health services must be prior authorized by the San Francisco Mental Health Plan. The SFMHP has contracted with some providers for specific school-based services, prevention programs, and other services that are not subject to this requirement. These provisions are defined clearly in those providers' contracts.
Authorization for Outpatient Mental Health Services
The Mental Health Access Team is responsible for providing initial authorization for all planned mental health services for individual and group practitioner providers and organizational providers. Providers can call the Mental Health Access Team to receive authorization or members may call the Mental Health Access Team directly to receive a referral to a participating provider. Members who prefer to walk-in to an outpatient mental health clinic (these are listed in Appendix 3) will receive referrals from Access Team staff on-site at those clinics. Clinics that do not have Access Team staff on-site will call the Access Team.
In order to obtain authorization for Outpatient Mental Health Services call the Mental Health Access Team at (415) 255-3737 or the toll free number at (888) 246-3333. The TDD Line is (888) 484-7200. Providers located in San Francisco should use the local number.
The Mental Health Access Team responds to requests for specialty mental health services from SFMHP members, providers, and other referring agencies 24 hours a day, 7 days a week. After confirming member eligibility and screening for medical necessity (Appendix 1) licensed Mental Health Access Team staff will provide authorization and referral to licensed individual and group mental health specialists and clinics providing outpatient treatment or refer the member to the most appropriate community service. Referrals will take into account language, cultural variables, age and other specialization, geographic location, and modalities of treatment. The Access Team will link requests for services for individuals in foster care and other Department of Human Services dependents to specialists with the Foster Care Mental Health Program at (415) 695-6975.
A copy of the authorization will be mailed/faxed to the provider and the member. The authorization will specify services by procedure code which are authorized for a given period.
The Access Team will link crisis calls to the mobile crisis teams for adult, child, and geriatric services (see below).
Authorization For Continuing Outpatient Treatment
Continuing authorization for outpatient treatment is required when additional services beyond the initial authorization are necessary. It is the provider's responsibility to seek prior approval of additional services prior to the expiration of approved sessions/visits. All providers except those operating Program Utilization Review Quality Committees (PURQCs) should call the Mental Health Access Team at (415) 255-3737 or the toll free number at (888) 246-3333 or fax the request for re-authorization to (415) 255-3629 using the form provided by the Access Team for this purpose.
Organizational Providers who operate PURQCs should follow the procedure described in Appendix 4 to obtain reauthorization.
All referrals for admission of children and youth to day treatment services are reviewed by an inter-agency committee. Contact: Stephen Ba˝uelos, L.C.S.W. at (415) 255-3411.
What To Do When Members Contact You Directly Requesting Services
Providers may call the Access Team directly for prior authorization if they already know the member. Otherwise, members should be encouraged to call the Access Team directly. (New referrals require information that members could provide more easily by calling themselves.) Providers who call the Access Team directly for new members will be expected to provide specific information about the member such as name, address, social security number, address and length of residency, Medi-Cal number, or financial information to establish indigency, such as monthly income.
Other Services Available From the Access Team
In addition to treatment authorization, the Mental Health Access Team provides the following services:
Referrals To 24 Hour Mental Health Services
Referrals to non acute 24 Hour Mental Health Services including long term care, the Mental Health Rehabilitation Facility, residential treatment, transitional residential treatment, residential care facilities, co-ops, and support hotels must be prior authorized by the San Francisco Mental Health Plan.
Exception: Acute Diversion Units (ADUs) for adults are available to accept direct referrals without SFMHP prior authorization as an alternative to hospitalization for individuals experiencing acute episodes or crises requiring temporary removal from their environment. Direct referrals to these programs must occur through the Progress Foundation Intake Coordinator at (415) 750- 9859. Referrals to ADUs post-hospital do require prior authorization by the SFMHP 24 Hour Services Review Team as described below.
All referrals for admission to 24 Hour Adult Care must be submitted to the 24 Hour Services Review Team. The standard referral form in Appendix 5 must be submitted by fax to the number listed below. Authorizations provided by the 24 Hour Services Review Team will incorporate auxilliary services that accompany the core service.
Tel. 255-3483/3670 Fax: 252-3004
All referrals for admission to 24 Hour Geriatric Care must be submitted to the Geriatric Utilization Management Committee. The standard referral form in Appendix 6 must be submitted by fax to the number listed below.
Tel. 255-3440 Fax 255-3496
All referrals for admission of children and youth to sub-acute or residential services are reviewed by an inter-agency committee.
Contact: Helaine Weinstein, L.C.S.W. at (415) 206-7612.
The State defines an urgent condition as a situation experienced by a member that without timely intervention is certain to result in an immediate emergency psychiatric condition which requires psychiatric hospitalization. (The State distinguishes urgent conditions from emergencies, which require voluntary or involuntary hospitalization and meet the criteria for medical necessity for psychiatric inpatient hospital services. Emergency services are described in a subsequent section.)
Providers are expected to offer urgent care services to their clients during regular hours of operations and to make provisions for after-hour coverage for their clients. If your client is experiencing an urgent psychiatric condition, the safety and welfare of your client is a paramount concern.
To receive authorization for payment for treating urgent conditions, you must call the Access Team prior to offering the service unless 1) you are designated through your contract or agreement with SFMHP to provide the service or 2) you have already been authorized for a service that could be used to provide urgent care. The Access Team will also assist members who call to locate urgent care services even when they are outside of San Francisco.
SFMHP members in crisis should first contact their provider if they have one.
SFMHP provides a number of services designed to assist in intervening with patients in crisis and determine the most appropriate services to be provided:
Urgent Care for Children and Youth
Child Adolescent Sexual Abuse Resource Center (CASARC) 995 Potrero at San Francisco General Hospital Campus, Room 319 Provides urgent care for child and adolescent victims of sexual abuse. Hours: 24 hours a day, daily
24 Hour Comprehensive Child Crisis Services
Provides children and youth and their families with crisis intervention, evaluation for hospitalization, consultation, home visits, short term psychotherapy, and referrals to community treatment programs. All referrals to hospitals for psychiatric admissions must be evaluated by Child Crisis Service.
Urgent Care for Adults and Older Adults
Westside Community Crisis Services
Mobile Crisis Treatment Team Services
Tel. (415) 970-4000
Geriatric Mobile Crisis Team
24 Hour Suicide and Crisis Hot-line Services
Tel. 781-0500 Offers a 24 hour a day, seven day a week, confidential suicide and crisis intervention phone line. San Francisco Suicide Prevention also offers a mental health information and referral line: (415) 981-4700, a Drug Line (415) 362-3400, and an AIDS/HIV Nightline (415) 434-AIDS.
EMERGENCY (UNPLANNED) SERVICES
An emergency psychiatric condition is defined by State regulations as one which requires voluntary or involuntary hospitalization and meets the criteria for medical necessity for psychiatric inpatient hospital services by meeting one of the following conditions as a result of a mental disorder:
No prior authorization for payment from the Mental Health Plan will be required for emergency services delivered by either in-plan or out-of-plan providers.
Emergency Psychiatric Hospital Admissions
Psychiatric Emergency Services (PES)
PES provides 24 hour, 7 day a week emergency assessment, stabilization and disposition , including hospital placement for acutely ill adult psychiatric patients. PES is the evaluation facility for adult patients placed on psychiatric holds ("5150").
In the event of an emergency psychiatric admission, hospitals are required to notify the SFMHP as soon as possible and no later than 24 hours of the time of the admission of the beneficiary. Emergency admissions must meet the criteria specified above.
Notification of admission may be made by facsimile or voice mail telephone within 24 hours of admission. (Contact the numbers below for information about what information to provide. ) SFMHP inpatient authorizations will incorporate both the facility and professional (psychiatrist/psychologist) services. The process for obtaining authorization is described in Appendix 19.
Inpatient Hospital Authorizations Adults and Older Adults
Inpatient Hospital Authorizations Children and Youth
Failure to notify SFMHP within 24 hours of admission may result in a payment denial for all or a portion of inpatient psychiatric services delivered.
Planned Hospital Admissions
For psychiatric conditions or crises that do not meet emergency criteria, all planned hospital admissions must be prior authorized by the San Francisco Mental Health Plan. Licensed mental health professional staff are available between 8 am and 4 p.m. and will respond to your call within 1 hour.
Documentation indicating that the member meets medical necessity criteria must be faxed prior to admission for the provider to receive payment authorization. SFMHP inpatient authorizations will incorporate both the facility and professional services.
PHARMACY AND LAB SERVICES
Pharmaceutical Services for Medi-Cal Members
Medi-Cal members obtain their pharmacy benefits through the Fee-for-Service Medi-Cal program or their health plan if they are enrolled in a health plan. Members who are enrolled in health plans continue to obtain certain medications (listed in Appendix 7) through the Fee-for-Service Medi-Cal program.
Pharmaceutical Services for Indigent Members
Indigent members of the SFMHP obtain their pharmacy benefits through the SFMHP Pharmacy Services. This benefit is available only to registered SFMHP members receiving authorized services from SFMHP providers. The SFMHP formulary is included in Appendix 8. Certain prescriptions require prior authorization which may be obtained by contacting the SFMHP Pharmacy Services at (415) 255-3659. This is described in policy #3.01-3. Prescriptions covered through this program must be written on specific forms for this purpose which will be provided by the Access Team along with the initial referral or by the Pharmacy Service if you call (415) 255-3659. These prescriptions will be filled by any of the pharmacies listed in Appendix 9.
For additional information about pharmacy services/policies for SFMHP members call (415) 255-3659 or fax (415) 255-3754.
Medi-Cal members obtain their lab benefits through the Fee-for-Service Medi- Cal program or their health plan if they are enrolled in a health plan. For information about arranging for laboratory services for indigent members of the SFMHP, contact Pharmacy Services at (415) 255-3659 or fax (415) 255-3754.