Medical Management Requirements Effective January 1, 2008

Transcription

1 December 1, 2007 Dear Provider and Colleague: Please be advised that effective January 1, 2008, Health Plan will change its Medical Management Policies to include new requirements for prior authorizations and referrals. Based on your feedback, and our data, these changes will result in improved effectiveness in meeting the needs of our Members, while simplifying your administrative processes. In fact, the use of an referral form will no longer be required as long as your referral document includes the following: 1. Identification of the patient as an Member 2. Clear clinical rationale for referral 3. Specific services required for which referral is being made 4. Name; specialty; address, phone number and appointment date and time for the specialist / ancillary provider and a copy of the referral must be kept in the patient (Member) record. The New Prior Authorization List and Request for Prior Authorization Form are enclosed. Please note: This information will be available on s Web Site: All authorizations and payment for services rendered are subject to the Member s continued eligibility on the actual date of service. If you have any questions, contact our Medical Management Department by calling: Our dedicated staff will be happy to assist you. As always, please do not hesitate to contact your Provider Relations Representative for general information about these requirements. Thank you for your continued care and service to our Members, your patients. Sincerely, Susan J. Beane, MD Senior Vice President & Chief Medical Officer sbeane@affinityplan.org Enc. Page 1 of 6

2 A Prior Authorization Request is a Service Authorization Request made by the Member, or a provider on the Member s behalf, for coverage of a new service, before the service is provided. Services rendered without a prior authorization request filed with or designated management services vendor may not be reimbursed by or designee. General Guidelines: Contracted providers must refer to in-network providers and/ or render services in innetwork facilities. All Out-of-Network services or care by a non-participating (non-contracted) physician or provider (i.e., laboratories; DME vendors; etc.), must receive prior authorization to be considered payable. Although Emergency Care does not require prior authorization, notification is required within 24 hours of admission. Service-specific Guidelines: The tables below describe the types of services requiring prior authorization as follows: First Column: Identifies type of service Second Column: Identifies the contact (organization) which will provide the authorization (end of document provides list of entities and applicable contact information.) Page 2 of 6

3 Medical Services Requiring Prior Authorization TYPE OF SERVICE All Elective Admissions Elective Out-of-Area care Out-of-Network Prenatal Care Experimental / Investigational Services Ambulatory Surgery Cardiac Rehabilitation Physical and Occupational Therapy Speech Therapy and / or Speech Generating Device Oxygen Therapy and Hyperbaric Therapy services (outpatient) Hospice Non-Emergent Ambulance / Ambulette Home Health Care, including personal care for transition and use of home ventilators Outpatient Mental Health and Substance Abuse Services Medically Necessary Contact Lenses Chiropractic Services (MEDICARE ONLY benefit) Erectile Dysfunction services Cosmetic Procedures Ultraviolet treatment CONTACT Beacon Block Vision Landmark Page 3 of 6

4 Drugs and Prescription Services Requiring Prior Authorization TYPE OF SERVICE Non formulary medication prescriptions to be filled at Pharmacy Synagis Botulinum Toxin Growth Hormone Lupron Monarch M Drugs prescribed for treatment of Erectile Dysfunction Medical, Enteral and nutritional Formulae prescriptions to be filled at Pharmacy Xolair Autologous cultured chondrocytes implant Durable Medical Equipment Requiring Prior Authorization Apnea Monitor for Members greater than 6 months of age Breast Pump and / or human milk storage Prosthetics using External Power Custom prosthetics Custom Orthotics Implantable Infusion pumps Home Equipment, including: Standing System Patient Lift Hospital Beds IPPB Machines Oxygen Therapy Pneumatic Compression Therapy Traction Equipment Incontinence Treatment System Osteogenesis Stimulator Wig Wheelchairs / Pediatric Gait Trainers CONTACT Express Scripts Express Scripts Page 4 of 6

5 Imaging Services Requiring Prior Authorization TYPE OF SERVICE PET Scan Cardiac CT Cardiac MRI CONTACT The following Case Management services do not require pre-authorization; however, please note specific referral and notification procedures which will apply: Specialist to serve as a Primary Care Physician - request may be initiated by Member or Member s assigned PCP or SCP to whom Member is referred by assigned PCP for ongoing care. *Case Management Services Case Management must be notified of such request. Upon which the Member s assigned PCP, in consultation with a medical director of, may agree to designate a specialist as a PCP. For example, this would apply to a Member with HIV. Member will then be transferred from PCP panel to such specialist as his or her PCP. Valid for 12 months. Standing Referral to a Specialist Request by PCP to waive routine renewal of referral when Members will require specialty care for a prolonged period of time for a life-threatening, degenerative and / or disabling disease or condition. Valid for 12 months. Continuity of Care Request for enrollee to continue an ongoing course of treatment with the enrollee's current health care provider during a transitional period Referral for Pre-Transplant related services Case Management should be contacted to coordinate specialty visits and services in-network. Referral for Bariatric Surgery and related services Case Management should be contacted as soon as a potential need for bariatric surgery is identified to assess and coordinate specialty visits and services Page 5 of 6

6 Medical Management Contact Information Department / Organization Phone Fax Medical Management Beacon Health Strategies (Mental Health and Substance Abuse Services) Block Vision (Optometry and routine Vision Services) Healthplex (Dental Services) Landmark (Medicare Advantage only) Express Scripts Prescription Pharmacy (Family Health Plus, Child Health Plus and Medicare Advantage only) (for pharmacies) Page 6 of 6