Mental Health

Your plan offers access to Mental Health, Behavioral Health Services, and Substance Use Disorder Treatment Services through Windstone Behavioral Health Inc. (a specialty Independent Practice Association). Treatment Services are coordinated and administered by Windstone. You do not need a referral from your PCP or from Windstone to see a Windstone Participating Provider for office visits for Mental Health, Behavioral Health Services, medication management or Substance Use Disorder treatment. Certain Mental Health, Behavioral Health and Substance Use Disorder services require prior authorization from Windstone. To view the prescription drug formulary, please visit the Prescription Drug List page.

Authorization, Modification and Denial of Health Care Services

Seaside Health Plan uses established utilization management (UM) criteria to approve, deny, delay or modify authorization of benefits based on Medical Necessity. The criteria used for evaluating requested health care services are based on empirical research and professionally recognized standards of practice. For Medical Health Care Services, SHP and its contracted Medical Groups use multiple nationally professionally recognized sources including Milliman Care Guidelines, InterQual, St. Anthony’s Medicare Benefit Guidelines and Hayes New Technology Assessment Guidelines.

Grievance Process

You can file a grievance for any issue. Your grievance must explain your issue, such as the reasons why you believe a decision was in error or why you are dissatisfied about Covered Services you received. Grievances may be submitted online, in writing or by telephone. You must submit your grievance within 180 days of the date of the incident that caused your dissatisfaction. For additional details on how to file a grievance, please visit GRIEVANCE FORM.

Continuity of Care

If your current healthcare provider is leaving the Seaside Health Plan network, you may be eligible for continuity of care if you have certain qualifying conditions. If you are a new member within Seaside Health Plan and are currently receiving active treatment from a provider who is not within the network, you may also qualify for Continuity of Care. Please refer to the Continuity of Care Program policies and if you qualify, you may submit an application. Please visit Forms and Documents to download the Continuity of Care policies and application.

Independent Medical Review

Please visit Forms and Documents to download an Independent Medical Review form.

You Can Apply for an IMR if your Health Plan:

  • Denies, changes, or delays a service or treatment because the plan determines it is not medically necessary
  • Will not cover an experimental or investigational treatment for a serious medical condition
  • Will not pay for emergency or urgent medical services that you have already received