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Summary Plan Description (SPD)
Medical Necessity – Request for Reconsideration of Denial and Appeals Procedures
This Mental Health and Chemical Dependency Benefits Program provides benefits only for clinically/medically appropriate treatment as determined by PBH.
The conditions which must be met for treatment to be deemed clinically/medically appropriate treatment are contained under the section titled “Integrated Member Assistance Program and Managed Mental Health & Chemical Dependency Benefits Program” subtitled "What Is Clinically/Medically Appropriate Treatment”?
The Program’s procedures for Reconsideration of a Denial and the Appeals Procedure for Denial of Treatment because it is deemed not clinically/medically necessary by PBH are outlined below.
In cases of emergency admission to a contracted PBH Network Facility, you should contact PBH within 48 hours or as soon thereafter as possible. This is for the purpose of having PBH manage your stay. In the event you do not notify PBH, you will still be eligible for plan benefits for medically necessary services.
PacifiCare Behavioral Health maintains a 24-hour toll free hotline at 1-877-225-2267. You can access this hotline at any time to find out how to receive treatment for mental health and/or chemical dependency needs.