Quick Authorization Form (QAF) - whose responsibilty to get referral ?

Referrals or Prior Notifications

A referral or prior notification is a request by a PCP or a participating specialist for a member to be evaluated and/or treated by a participating specialty physician and/or facility. SHP uses two types of forms and processes:

1. Quick Authorization Form (QAF)

For those services included on the SHP Quick Authorization Form (QAF) (see the Forms Section of this handbook) a referral is NOT required. Primary Care Physicians (PCP’s) can refer a member to a   articipating specialist and to many frequently requested services and procedures at free-standing facilities with the Simply Healthcare Plans Quick Authorization Form (QAF) without contacting the health plan for prior authorization.

IMPORTANT NOTE: Communication with the Plan prior to the provision of care is not necessary when using the QAF; however, all inpatient services, outpatient hospital services (including diagnostics), and ASC services do require an authorization (see section below).

Prenatal care referrals are NOT to be made using the QAF.

**The QAF form is not valid for any inpatient or outpatient hospital services or for any consultations or procedures not listed on the form, or for out-of-network providers.

The PCP or specialist ordering the consultation or test is required to fax or mail a copy of the completed QAF to the participating provider or facility that will be providing the service(s), or to give a copy to the member so that it is presented at the time of the service.

Services that Do NOT Require Prior Authorization or QAF:

* Family Planning*
* Participating Office/free standing laboratory tests at labs consistent with CLIA guidelines
* Emergent transportation services
* Urgent or emergent care at participating Urgent Care centers or any Emergency Room
* County Health Departments (CHD), Federally Qualified Health Centers , Rural Health Clinics and
federally funded migrant health centers when providing:
* Vaccines
* STD diagnosis/treatment
* Rabies diagnosis/immunization
* Family planning services and related pharmaceuticals
* School health services and urgent services

*NOTE: If the member receives Family Planning Services from a non-network Medicaid provider, the Plan will reimburse the provider at the Medicaid reimbursement rate, unless another payment rate is negotiated.


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