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Pre-certification
of All Mental Health Services
Pre-certification
is based on goal directed care, and focused treatment objectives with
an emphasis on improving specific functional impairments. It is a utilization
management tool that ensures that members receive medically necessary,
cost-effective health care and case management services. Health professionals,
hospitals and other providers are required to comply with the Pre-certification
policies and procedures. Noncompliance may result in delay or denial
of payment for services. Pre-certification is required for Health Plans
serviced by St. John's Mercy Managed Behavioral Health (SJMMBH).
Q.
How do I pre-certify services or check on an authorization?
A. Contact SJMMBH directly at:
(314) 729-4600 extension 1 or (800) 413-8008
Q.
If services are pre-certified, does this mean the member is eligible to
receive services?
A. To ensure that a member is eligible the following steps should be taken
at the time of service:
- Verify eligibility
- Verify member's
identity, if unknown
- Verify Prior Authorization
or Certification
- Secure Prior Authorization
or Certification
- Collect appropriate
co-payment
- Bill third party
administrator
Q.
How do I get more sessions?
A. After the member has been seen for the initial number of visits, you,
the provider, must submit a treatment plan with measurable goals and identified
progress to SJMMBH prior to seeing the patient. SJMMBH must receive the treatment
plans at least 3 working days before the appointment for the treatment
plan to be reviewed and additional visits authorized. If there must be
an emergency appointment, please call (314) 729-4600 extension 1 or (800)
413-8008 to have that visit authorized.
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