A network referral allows a member enrolled in a primary care coordinator (PCC) plan from a participating care provider other than a PCP at the benefit level. We require one when we are the primary or secondary payer. A referral does not guarantee payment of a claim.
Network Referral Process for Primary Care Coordinator (PCC) Plans
The network PCP must initiate referral requests. Requests may not come from specialists. If the treating specialist feels the member must see another specialist, they must contact the PCP. The PCP makes the final decisions about referrals and must make any new referrals.
Standard Exceptions to the Network Referral Process
- Female members may directly access network OB/GYN providers without a referral.
- Members may directly access network ophthalmologists or contracted vision providers for an annual diabetic dilated eye exam without a referral.
- Members with a split copayment (where they have one copay for PCP visits and a higher copay for specialty visits) do not require a referral to a network specialist.
Process to Facilitate Network Referrals
The PCP decides whether a member needs for a network referral. They communicate this to the member. Then they either mail, call or fax the referral to the specialist. The PCP states the requested services in the referral.
Referral requests must be for services covered under the member’s benefit plan to a participating care provider.
To facilitate coordination of care, the PCP should promptly relay clinical information to the specialist. The specialist should also provide written communication to the PCP, describing the rendered health services.
A specialist submits claim(s) for services, providing the PCP’s name and UPIN/NPI number in boxes 17 & 17a of the CMS 1500 form. Place the River Valley universal referral number 2009061 RV in Box 23 of the 1500 claim form to serve as authorization for payment at the member’s network benefit level.
An out-of-network (OON) referral means a written authorization provided by a participating care provider and approved by us for services to be received from a non-participating care provider. OON referrals must be requested by the member’s PCP. If an OON referral is obtained, services received from a non-participating care provider are covered at a network level of benefits under the member’s benefit plan. An OON referral is needed when services are not available from a participating care provider and may be needed for various services including, but not limited to, podiatry, chiropractic and mental health/ substance use services.
Out-of-Network Referral Approval
A referral to an OON care provider must be approved by us before the services are rendered. We must also give prior approval for modified or expired OON referrals as described in this supplement. We may approve an OON referral when services are needed but not available from a participating care provider. Prior approval of an OON referral is required for each follow-up visit unless we indicate otherwise. A medical director will review requests that do not meet approval criteria.
In the case of emergencies, notify us the first business day following the referral.
Out-of-Network Referral Process
To determine whether an OON referral is necessary under a member’s benefit plan, contact us at the number on the back of the member’s health care ID card.
Get prior approval by completing an OON referral request form. Then fax it to us with supporting documentation. The OON referral request form can be accessed on uhcrivervalley.com > Providers > Forms > Out-of-Network Referral Form.
- We will make decisions within the time frames required by state and federal law (including ERISA) and in accordance with NCQA standards.
- We will send a letter confirming our approval or denial of a referral to the member and your office
- If a member requests approval after the fact, advise them this is against policy. Refer them to the following numbers: Illinois/Iowa/Wisconsin: 800-747-1446; Tennessee/Virginia/Arkansas/Georgia: 800-224-6602.
Participating care providers may not refer their own family members to non-participating physicians/facilities due to conflict of interest. If the care provider denies a referral, the care provider must refer the member to their benefit document for any appeal rights. Or have them call:
- Illinois/Iowa/Wisconsin: 800-747-1446;
- Tennessee/Virginia/Arkansas/Georgia: 800-224-6602.