|
Member Referral Process
Health Advantage members with an HMO or point-of-service (POS) policy must choose
a primary-care physician (PCP) to coordinate their medical care. When needed, the
PCP will refer the member to an appropriate in-network specialist.
Members with an open access policy may or may not choose a PCP. It is not mandatory,
but it is encouraged. Referrals are not required with an open access plan. (Your
member ID card will indicate if your plan is "open access.")
Written Authorization
For referrals, PCPs use the "script" method. The PCP may give the patient a written
authorization form to be taken to the appointment with the in-network specialist
or fax the form to the in-network specialist. The in-network specialist or in-network
facility then uses the referral number when filing the claim with Health Advantage.
Members are responsible for obtaining the referral prior to receiving services from
a specialty provider. Failure to obtain the referral prior to services will result
in the claims either being denied or going toward the lower level of benefits depending
on the member's plan. Health Advantage suggests that members always verify that
the specialist is participating with Health Advantage prior to the visit. Also,
if a participating provider orders supplies or durable medical equipment, please
verify that the supplier is participating with Health Advantage. You can verify
provider participation by either calling Customer Service or using the
Provider Directory.
For a referral to a specialist not participating with Health Advantage (out-of-network),
the member's PCP must submit an out-of-network referral request to Health Advantage
for possible coverage authorization. If the member is on an open access policy and
does not have a PCP assigned, Health Advantage will accept an out-of-network referral
request from another participating provider that has seen the member for the same
medical condition currently being treated. There are very few, if any, specialty
services that are not available from an in-network specialist.
Note that retroactive referrals are discouraged and may not be authorized for coverage.
Exceptions:
- Female members do not need a referral from a PCP or Health Advantage for annual
obstetrical/gynecological (Ob/Gyn) checkups, as long as members visit an in-network
physician.
- Plans that have routine eye-care benefits will not need a referral for that visit
as long as the ophthalmologist or optometrist is a participating provider.
- Emergency care and urgent care do not require referrals. Refer to your Evidence
of Coverage for definitions of emergency care and urgent care and any procedures
you need to follow.
|