PMHM’s Professional Guided Care Program SM seeks to ensure that each patient receives the correct treatment in the most appropriate treatment setting. After the expiration of PMHM’s initial authorization, the Provider may request more treatment sessions or days as required. Regardless of PMHM’s authorization with regard to benefit payment, the Provider must provide the amount and type of treatment each patient requires.
In the event that PMHM denies further benefit payments, the Covered Member may initiate an appeal (you may call PMHM to assist the patient in this process). PMHM’s Case Management System has a three-tiered approach, initially using clinical peer review and using independent reviewers at the highest level of appeal. PMHM’s timeliness standards for Clinical Appeals are one (1) business day for expedited appeals and ten (10) business days for standard appeals. In all appeals PMHM requires that the patient’s full medical record be submitted. For more information about PMHM’s Appeals Process or to initiate an appeal, you may call 800-776-4357.
