***Self-Referrals do NOT apply to PEDIATRIC Patients***
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- Amie Bennett
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1 THIPA has 3 types of Referrals: Self Referral Direct Referral Patient needs to be referred by their THIPA physician to see a Specialist or obtain a Test. This can be done by paper referral form, physician order on a prescription pad, or by recognized ordering mechanism (paper or electronic). Authorization Required Patient may call contracted THIPA physician at will and make an appointment No authorization or approval by THIPA is required. THIPA provider needs to submit request for service on behalf of the patient to the THIPA Utilization Department via Synermed or faxed authorization form for Utilization review. Patient may not receive service until approval of the requested medical service has been obtained from THIPA. 1A. Self-Referrals: Adult patients may seek out a Specialist in any of the Medical Specialties below by making an appointment without a referral or authorization SPECIALTY Cardiology Dermatology Gastroenterology Gynecology Orthopedic Surgery OB/GYN Podiatry Pulmonary Medicine Urology Notes or Exceptions Patients under 16 years of age are a direct referral Patients under 16 years of age are a direct referral Patients under 16 years of age are a direct referral Self-Referral for consultations & routine preventive services only. Section 2 outlines specialty services requiring Authorization. Excludes Hand Surgeon which must be requested by a general Orthopedist Self-Referral for consultations & routine preventive services only. Section 2 outlines specialty services requiring Authorization. Patients under 16 years of age are a direct referral Excludes sleep consults and equipment Self-Referral for consultations. Section 2 outlines specialty services requiring Authorization. ***Self-Referrals do NOT apply to PEDIATRIC Patients***
2 1B. Direct Referrals: A THIPA Physician/Provider may refer any Patient (ADULT and PEDIATRIC) for the services below by a THIPA contracted provider by completing a THIPA Referral Form and faxing it directly to the provider without requesting authorization from THIPA. Direct Referrals are used for: ABGs & PFTs (fax to Peninsula Pulmonary Medical Associates) Allergy Cardiology Cardiothoracic Colon/Rectal Surgery Coumadin Clinic (fax to Peninsula Pulmonary Medical Associates) C-section, repeat c-section, and vaginal delivery (to be done at TMMC) EEG (adults only, to a THIPA neurologist) Emergency Department visits ENT/Otolaryngology except for OSA evaluation or sleep disturbances General Surgery Hematology/Oncology Immunizations for <18-year-olds Infectious Disease Lab Quest Mammograms Neonatology Nephrology (except for hemodialysis) Neurology Otolaryngology Orthopedics Pathology (to Quest Lab only) Pediatric cardiology Pediatric endocrinology Pediatric Hematology / Oncology Pediatric Gastroenterology Pediatric Nephrology Pediatric Neurology - EEG direct to TMMC EEG lab Pediatric Urology PFTs & ABGs (to THIPA Pulmonologist office) Physical Medicine and Rehabilitation (physician professional services) Radiation Oncology Vascular Surgery
3 1B (a). Direct Referrals to TMMC Radiology can be made by any THIPA Physician/Provider for the radiographic tests listed below without authorization. (Facility co-pay may apply.) Abdominal Film (KUB) and upright Barium Enema Barium Swallow Bone or Joint X-rays Bone Density Study (BDS) or DEXA Females o 50 years of age if no BDS was done in the preceding 12 months o (Less than 50 years of age requires authorization) Males aged 70 or older Breast: ultrasound, aspiration and biopsy, needle core biopsy, cyst aspiration, stereotactic needle biopsy, fine needle aspiration. Chest X-rays Esophagram Intravenous Pyelogram (IVP) Mammograms Routine screening for asymptomatic women as follows: 35 or younger requires authorization Scanograms Sinus X-rays Small Bowel Ultrasounds / Sonograms / Echoes Abdomen Breast Carotid Gallbladder Head Hip Kidney Liver Non-invasive vascular (e.g., for DVT) Pelvis Testicle Thyroid Transvaginal Upper GI Series
4 VQ Scans
5 1B (b). Direct Referrals to TMMC Radiology can be made by a designated THIPA Specialist for the radiographic tests without authorization as outlined below. (Facility co-pay may apply.) ( Note: TMMC has an open MRI when necessary). Allergists CT Sinus Cardiologists CT Chest MRI/MRA Heart Renal scan Cardiothoracic Surgeons CT Chest MRI/MRA Heart Endocrinologists CT of Neck/Chest FNA with Bx Nuclear Thyroid Scan ENT see Otolaryngologists Gastroenterologists CT Abdomen/Pelvis HIDA / PIPIDA Scan MRI Abdomen/Pelvis Ultrasound-Guided Biopsies Bacterial Overgrowth test H. Pylori breath test General Surgeons CT Abdomen/Pelvis HIDA / PIPIDA Scan MRI Abdomen/Pelvis Oral Cholecystogram Renal Scan Gynecology CT Abdomen/Pelvis MRI Pelvis/Pelvis Ultrasound Pelvis Gyn/onc CT Abdomen/Pelvis MRI Abdomen/Pelvis Hematologists/Oncologists Bone Scan CT Brain/Chest/Abdomen/Pelvis MUGA Scan MRI Brain/Chest/Abdomen/Pelvis Hospitalist: CT Brain/Chest/Abdomen/Pelvis Echocardiogram Exercise Treadmill Test MRI Brain Nuclear Stress Test Nephrologists CT Abdomen/Pelvis Cystogram MRI Abdomen/Pelvis Renal Scan Neurologists & Neurosurgeons CT Brain MRI/MRA Brain MRI cervical/thoracic/lumbar spine Oncologists - see Hematologists Orthopedic Surgeons Bone Scan CT Limb/Joint MRI Limb/Joint MRI cervical/thoracic/lumbar spine Scanograms Otolaryngologists CT Head/Neck/Sinus FNA w/ Bx MRI Head/Neck/Sinus Podiatry MRI of feet
6 Pulmonologists CT Chest Radiation Oncologists Bone Scan CT Brain/Chest/Abdomen/Pelvis MUGA Scan MRI Brain/Chest/Abdomen/Pelvis Urgent care (TMMC/THIPA) CT Brain/Chest/Abdomen/Pelvis Echocardiogram Exercise Treadmill Test MRI Brain Nuclear Stress Test Urologists Bone Scan CT Abdomen/Pelvis Cystogram MRI Abdomen/Pelvis Renal Scan Vascular Surgeons MRI Chest/Abdomen/Pelvis/Limb Vascular MRA (Brain and Peripheral)
7 2. Services Requiring Authorization by THIPA 2(a). Contracted Services requiring Authorization by THIPA; **Denotes that Provider will be determined by THIPA Acupuncture Allergy and/or Asthma - RAST test (Blood test) Audiology Examples: - Exams for hearing aids - Hearing Aids Autologous/Donor Directed Blood (including storage) Bariatric Surgery ** Behavioral Health (Some senior plans and all commercial plans have carve-outs. See below) Chemical Dependency - Medical in-patient detox - Out-patient detox - Out-patient rehab Chiropractor Clinical Trials Dental Anesthesia at TMMC Dietician at TMMC Diabetic Nurse Education at TMMC Durable Medical Equipment ** ECG, echocardiogram or Holter monitor at TMMC (direct by THIPA cardiology) EEG (if to TMMC) Elective Procedures/Outpatient Surgeries (see TMMC) Endocrinology ERCP with or without sphincterotomy Extended Care Facility (ECF/SNF) Family Planning - see OB/GYN Genetic Testing & Counseling, non-ob related ** GYN see OB/GYN for examples GYN Oncology Hemodialysis/Peritoneal Dialysis Home Health ** Hospice ** Immunizations - Examples: - Dtap >9 years - Gardasil for boys and girls <9 or >26 yrs - Hepatitis A&B >18 years - Meningococcal vaccine <18 years - Pneumovax < 60 years - RSV (Synagis) -Travel Immunizations Infertility Treatment: Female: Initial workup and treatment by Ob/Gyn, then Ob/Gyn (ONLY) refers to infertility Male: Refer to urology. Injectables (includes self) examples: - Epogen/Procrit - Growth Hormones - Imitrex - Interferons - Lupron - Neupogen - Remicade OB/GYN Services - Examples: - D & C - DepoProvera - Diaphragm - Elective Abortion to Family Planning Associates - Infertility (see Infertility above) - IUD - Norplant - Perinatology - Pessary - Tubal Ligation
8 Neurosurgery Opthalmology & Optometry Oral Surgery Orthotics** Pain Management Pediatric General Surgery Pediatric Infectious Disease Pediatric Opthalmology Pediatric Orthopedic Surgery Pediatric Pulmonology Pediatric Rheumatology Perinatology Physical Therapy - to IPT Plastic Surgery Prosthetics ** Psychiatry / Psychology Radiology Complex imaging ordered by PCP (CTs, MRIs, PETs) Radiation Oncology - IMRT Rehabilitation Services - Examples: - Biofeedback - Cardiac Rehab - Occupational Therapy - Physical Therapy - to IPT - Pulmonary Rehab - Speech Therapy - Vestibular Rehab Rheumatology** Second Opinions for any Specialty Skilled Nursing Facility (SNF) Sleep Study Sleep Consultation Surgery, Outpatient Temporomandibular Joint (TMJ) Tertiary Providers: o (e.g., UCLA, USC, etc) Consultation and Procedures TMMC elective inpatient and outpatient surgeries, procedures, outpatient services, education, etc. o (e.g., bronchoscopy, dietary consult, diabetic education, wound care, burn clinic, etc.). Transplants (organ, BMT, etc.) Urology - Examples: - Circumcision (except newborns) - Impotence (Injections / Devices) - Male Infertility - TUMT - Vasectomy (reversal not covered) ** Do not specify provider THIPA to determine ** For some services, a facility co-pay may apply
9 2 (b). Behavioral Health Providers by Health Plan
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11 3. Authorization Submission Process 1. Providers offices are responsible for validating eligibility prior to each visit. 2. Fast track your request! Send comprehensive clinical information when you submit your request. Not providing the necessary clinical information can delay the process by as much as 45 days. 3. Submit for authorization a separate faxed referral form to the UM department at (424) or (424) or electronic request via Synermed on the same day the form is dated. 4. Submit a separate faxed referral form or electronic request via Synermed for multiple providers or multiple DME items when requesting authorization. They each get reviewed separately against the patent s healthplan benefit 5. Mandated Turn Around Times for Authorization Requests: ROUTINE URGENT 5 Business Days from receipt of Authorization Request 72 Hours from receipt of Authorization Request 6. For Urgent Authorization, please call (310) THIPA autofaxes approvals, pended, cancelled or denied requests to all appropriate providers. 8. Authorizations are limited to: a 90 day window (you can request an extension) or The number of visits authorized or The expiration date printed on the authorization. 9. The requesting physician is responsible for notifying the patient of the approval/denial within 2 business days. 10. THIPA is responsible for mailing letters regarding approvals, denials, and pended requests to all Medicare Advantage Members. 11. THIPA is also responsible for contacting Medicare Advantage Members by phone and in writing for all medically Urgent requests.
12 4. SynermedConnect If the member does not appear in SynermedConnect (or is shown as not eligible): Verify or submit eligibility on the member s insurance plan website. For SynermedConnect access, please call: Jasmine Roodbari, , or Your THIPA Provider Relations representative o Patrick Hicks, o Cindy Knokey, For Trouble-shooting SynermedConnect, please call: SynermedConnect Technical Support at Utilization Management Department Telephone List EXT 5330 for Routine Utilization Management questions and for Utilization Management Fax Requests URGENT LINE For medical professionals only Exclusively for acute medical issues requiring authorization M-F 8:30-5:00 No voic . Always answered live.
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Allergen specific, each allergen is covered up to 50 units per patient annually; additional units would require medically necessary review.
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