PCP Referrals - when and why it require

The PCP is responsible for determining whether a referral for specialty care or ancillary service is appropriate. Referrals may be required when the member fails to respond to current medical treatment, to confirm or establish a member’s diagnosis and/or treatment modality, or to provide diagnostic studies, treatments, procedures or equipment that ranges beyond the scope of availability of the PCP’s services. Prestige
Health Choice does not require an authorization as condition of payment for referrals to network specialists and for routine laboratory testing (laboratory and plain X-rays performed at non-hospital-based outpatient facilities). Certain in-office diagnostic tests and procedures that are considered by the health plan to be a routine part of an office visit may be conducted as part of the initials visit without authorization.

When the PCP determines that a member should be referred to a specialist, the PCP should review the current specialty provider listing to select a Prestige Health Choice network specialist. To authorize the referral, an electronic referral form located on the Prestige Website (http://www.prestigehealthchoice.
com/proreferral) is completed. If the office does not have access to the on-line version, paper forms are available.

A copy of the paper form is included in the forms section of this manual. The referral form indicates all the services approved to be done by the specialist as well as the number of visits authorized and the duration of the approval. A copy of this form is provided to the member and a second copy is mailed or otherwise delivered to the specialist’s office. If the specialist must perform testing or procedures that is to be performed outside of their office and/or requires prior authorization, the specialist requests authorization from Prestige UM Department by fax (1-800-338-4195). The Specialist is required to fax a copy of the initial PCP referral
for to the UM department along with the prior authorization request.

When the PCP or specialist determines that a member should be referred for a diagnostic procedure, the PCP or specialist should review the current ancillary provider listing to select a network free-standing diagnostic provider. Prestige Health Choice will not authorize coverage of a routine diagnostic
procedure performed at a hospital when a free-standing facility is available.

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