Close-Up:
Rebecca And Ronnie

Rebecca and her daughter, Ronnie, have had a tough year. Rebecca has had a series of unhappy personal and professional experiences and would like to see a therapist for counseling. Ronnie has a serious mental illness - she has been diagnosed with bulimia nervosa.

Rebecca is enrolled in the Regular Plan. Her friend Charlotte recommends her therapist, who isn't a PBH provider, and Rebecca makes an appointment to see him. But at the last minute, Rebecca refers to her Summary of Benefits and discovers that if she sees a non-PBH provider, the plan will pay 70% of R&C charges, whereas if she sees a PBH provider, she'll pay just a $15 copay. In addition, the plan covers up to 20 outpatient visits a year with a non-PBH provider compared with up to 45 outpatient visits a year with a PBH provider. Rebecca makes some calls and gets the name of a PBH provider, who she can see for up to 45 outpatient visits a year by just paying a copay for each visit, assuming she obtains precertification.

Ronnie is also enrolled in the Regular Plan. Because her therapist is a non-PBH provider, the plan covers a maximum of 20 outpatient visits a year. After Ronnie's 20 visits, her therapist recommends that Ronnie be admitted to a mental health facility. Rebecca realizes that the plan will pay higher benefits if Ronnie goes to an inpatient PBH facility, so she and the therapist obtain precertification for inpatient treatment at a PBH facility.

How To Percentify Mental Health And/Or Substance Abuse Care
To receive the highest level of benefits, you need to see a PBH provider, who will work with PBH to precertify your care. It is your responsibility, however, to first call PBH to verify that the provider is in the PBH network. You must also make sure the provider precertifies your initial and ongoing care, which must be considered medically necessary in order to be authorized by PBH. If you go to a PBH provider but don't precertify your care, your benefits will be paid at the non-PBH level and will be subject to non-PBH provider limits.

Precertification (for PBH providers) is required for:

• All inpatient admissions for mental health care; and
• All outpatient mental health treatment.

Generally, you should precertify inpatient treatment 7 to 10 days in advance by calling PBH. Any facility-based treatment - for example, inpatient rehabilitation, partial hospitalization*, residential treatment* or an intensive outpatient program - that is pre-planned should be precertified ahead of time.

If you're admitted to the hospital or other facility because you have a mental health emergency, you must precertify within 48 hours (or two business days) of your admission by calling PBH. Your case will be assigned to a team of clinical care managers.

During a stay at a hospital or mental health facility, you may not use your outpatient benefits.

* For benefit purposes, one partial hospitalization or residential treatment day is equal to one inpatient hospitalization day.

* Beginning October 1, 2004, for benefit purposes, intensive outpatient visits are equal to one outpatient visit.