Billing Manual for Community Care Network Providers

A behavioral health emergency is the sudden onset of a behavioral health conditionmanifesting itself by acute symptoms of sufficient severity that the absence ofimmediate medical or clinical attention could result in seriously jeopardizing orendangering the mental health or physical well-being of the member or seriouslyjeopardizing or endangering the physical well-being of a third party. Behavioral healthemergencies are of two types:A life-threatening behavioral health emergency is a behavioral health conditionthat results from a mental illness or substance use disorder. There is reason tobelieve the member is, or may become, homicidal or suicidal or the member ormember’s victim may suffer a disabling or permanent physical injury as a result ofthe member’s behavior or condition. The assessment that a life-threateningemergency exists is based upon statements or behavior, member self report, orinformation obtained subjectively or objectively and clinical judgment.Care is required immediately for life-threatening emergencies.A non-life-threatening behavioral health emergency is a behavioral health conditionthat results from a mental illness or substance use disorder from which the membermay suffer significant physical or emotional deterioration resulting in hospitalizationor partial hospitalization unless an intervention is made within one hour.Care is required within one hour for non-life-threatening emergencies.Emergency services do not need precertification (preapproval) by Community Care.Community Care expects that the emergency room, mobile crisis service, or outpatientprovider will take immediate action for the safety of the member and others and willregister with Community Care for outpatient services as soon as the situation isstabilized.If Community Care is contacted regarding a member’s need for an emergency service,Community Care will provide a referral to an emergency provider, help arrangeemergency transportation through the member's physical health managed careorganization (PHMCO) and ensure that emergency services are made availableimmediately or within one hour of the contact. The customer service representative mayfollow up with the provider to ascertain compliance with this standard for access toservices.IV.D.2 Urgent Behavioral Health ConditionsUrgent behavioral health conditions of either of the following constitute an urgentsituation:As a result of a mental illness or substance use disorder, a member is experiencingsigns, symptoms, or impairment in functioning that would likely require an intensivelevel of care within 24 hours if treatment is not providedCommunity Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 93