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    PCR BH Provider Resource Guide

    The Peninsula Coastal Region Behavioral Health (PCR BH) panel serves approximately 12,000 employees and their dependents who are members of the SutterSelect PCR health plan. The following information serves as a resource guide for providers on the PCR BH panel.

    Plan Options

    Eligible employees choose from two plan options—an EPO or a PPO. Sutter Health employers that sponsor the SutterSelect PCR health plan include Menlo Park Surgical Hospital, Mills Health Center, Mills-Peninsula Medical Center, Sutter Maternity & Surgery Center of Santa Cruz and Palo Alto Medical Foundation.

    The EPO plan option has two copay tiers for outpatient behavioral health benefits.

    • EPO
      Provider Network: PCR BH
      Outpatient Copay: $15
      Plan Design: In-network benefits only

      Provider Network: Optum
      Outpatient Copay: $25
      Plan Design: In-network benefits only
    • PPO
      Provider Network: PCR BH or Optum
      Outpatient Copay: $15
      Plan Design: In-network and out-of-network benefits

      Provider Network: Out-of-network
      Outpatient Copay: Employee pays 30%
      Plan Design: In-network and out-of-network benefits

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    Member Benefits

    The SutterSelect PCR health plan’s mental health and substance disorder benefit encompasses all levels of care (facility-based inpatient, partial hospitalization, intensive outpatient, residential levels, and provider-based outpatient treatment) for medically necessary treatment. For a full list of coverage and exclusions refer to the SutterSelect Peninsula Coastal Region Self-Funded Health Plan Summary Plan Description (SPD). If providers or members have concerns regarding whether a diagnosis or treatment procedure is a covered benefit, they can also contact PCR BH by calling (855) 729-4390 or complete a Prior Certification Request.
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    Member ID Cards

    Members will receive a member ID card that contains the following information:

    • Plan name
    • Plan option
    • Copay amount
    • Claim submissions including an ID and a mailing address
    • Customer service phone numbers for both PCR BH and Optum
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    Member Access to Care

    Members Seeking Service
    If a member contacts PCR BH for assistance in locating a provider, appropriate providers will be identified and contacted. Providers are expected to respond promptly to calls from PCR BH. If the provider accepts the case, the member will be notified to call the provider for an appointment.

    Provider Directed Care
    If a contracted PCR BH provider determines that additional care by another behavioral health provider is warranted s/he should call PCR BH for assistance.

    Facility Treatment Referrals
    If a provider determines that the member needs and would benefit from facility-based treatment, the provider should contact PCR BH (24/7) to obtain Prior Certification. If urgent or emergent, the member should be directed to the nearest behavioral health facility or emergency room.

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    Prior Certification

    The below Mental Health and Substance Abuse Services require prior certification. Call PCR BH at (855) 729-4390 to request prior certification.

    • All day/partial Hospital or residential programs for mental health or substance use disorders
    • All intensive Outpatient program treatment for mental health or substance use disorders
    • Outpatient electro-convulsive treatment
    • Psychological and neuropsychological testing
    • Methadone maintenance
    • Extended Outpatient treatment visits for mental health or substance use disorders beyond 45-50 minutes in duration with or without medication management


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    Informed Consent

    At the first outpatient session, members must be asked to read and sign the provider’s informed treatment consent statement and related HIPAA consents. The informed treatment consent should include notification regarding confidentiality (Tarasoff, duty to report child and elder abuse, threat to self), responsibility for copays and medical necessity. This form must be maintained in the member’s patient record.
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    Member Copays

    Copays should be collected when applicable.
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    Worker's Compensation

    If the provider determines that the member’s condition is a function of a workplace injury or workplace emotional/psychological abuse or stress, the provider or member should contact PCR BH for direction. Further treatment should not be provided without first notifying PCR BH.
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    Treatment for Non-covered Services or Lack of Medical Necessity

    If a member receives a denial of a prior certification request due to the condition being excluded from the plan or due to lack of medical necessity, the provider may provide treatment to the member on a self-pay basis. However, the provider is expected to have the member sign a statement that explains all payment for the treatment is the responsibility of the member.
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    Expectations of Providers

    Providers are expected to maintain the following standards of care and conduct:

    • Notify PCR BH of changes to their availability and to obtain coverage by another PCR BH provider during any absences.
    • Have a greeting on their telephone answering message which informs members how to reach them in urgent situations and to go to an emergency room or to call "911" in an emergent situation.
    • Maintain ethical and legally mandated professional conduct at all times in treating and responding to members and former members.
    • Provide for the orderly transition of care throughout treatment levels in such a manner that the member receives continued clinical support with clinical information, whenever possible, preceding the transition through levels of care and providers.
    • Seek consultation when appropriate.
    • Maintain federal and state confidentiality laws and regulations, including HIPAA requirements for the protection of personal health information.
    • Maintain separate clinical records for each member, containing assessments, progress notes, releases and consents. Each member is expected to have a written clinical assessment and treatment plan no later than by the end of the third session.
    • Communicate with the member’s physician and/or other mental health/substance disorder providers to provide for coordination of care.

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    Provider Website

    The SutterSelect Provider website sutterselect.tpa.com provides access to information and tools for managing your patients covered by SutterSelect 24 hours a day, seven days a week. Logging on to this website provides you and your office the following:

    • Claim inquiry information such as payment status, amounts billed and paid, deductibles, discounts and to whom payment was made.
    • Eligibility and benefits information, including patient specific plan information, claim submission details, prior certification requirements and member benefit levels.
    • Access to the SutterSelect Peninsula Coastal Region Self-Funded Health Plan Summary Plan Description (SPD). The SPD is the official legal document for the medical plan. The SPD describes what benefits are available under the plan, the rights of members under the plan and how the plan works.
    • A guide to navigating the provider website is available in the SutterSelect Administrative Manual. This Manual is also located online at sutterselect.tpa.com. If you do not already have a username and logon, click "Need a Username? Register here." to complete the registration process using your name and password.


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    PCR BH Providers - Downloadable Forms


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    Printable Provider Resource Guide

    A printable PDF version of this resource guide is provided for your convenience.
    PCR BH Provider Resource Guide (PDF)

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