REFERRAL / PREAUTHORIZATION QUICK REFERENCE GUIDE

Transcription

1 REFERRAL / PREAUTHORIZATION QUICK REFERENCE GUIDE This Quick Reference Guide was created to help Healthcare Resources NW (HRNW) participating providers easily identity when a referral or preauthorization is typically required. This document is not all-inclusive and providers seeking to provide service to HRNW members are encouraged to also review HRNW Policy 700 prior to providing services to any HRNW Member. For a list of par providers, please refer to and click on For Providers. Select Medicare Advantage HMO and scroll to Participating Providers. HRNW reserves the right to retrospectively review any and all services provided to HRNW Members for medical necessity. Any services provided to an HRNW Member that are determined to not be medically necessary will not be reimbursed. Providers may appeal any claim denial for lack of medical necessity by submitting to HRNW Claims supporting documentation clearly outlining the reason the provider believes the services were medically necessary. However, a Provider s appeal does not guarantee claim payment. For participating facilities, discharge planning for inpatient admissions will be monitored by Care Management. Important: There is no benefit coverage for a Member s self-referral to a HRNW participating (par) or nonparticipating (non-par) provider. Contact number for HRNW for Utilization or Case Management (877) or Fax (503) Case and Complex Case Management Requirement Notify HRNW for the following: Immuno Therapy; Potential transplant case (e.g. bone marrow or organ); Catastrophic case (e.g. trauma, burns, metastatic cancer); Institutionalized Members. Non-Participating Providers Any service provided by a non-par Provider/Facility to a HRNW Member requires a referral and/or authorization. Participating Providers Not Identified in Table 1 or Table 2 For those par Providers not associated with clinic offices in Table 1 or Table 2 please see column 2 in Table 3. Participating Providers Identified in Table 1 or Table 2 Tables located on the following pages. 1 P a g e

2 Medical Group & Tuality Health Medical Group Providers associated with the provider offices in Table 1 can refer and provide services amongst themselves without needing to submit a referral or authorization to HRNW except as outlined by column 3 in Table 3 (marked as ). TABLE 1 Name Organization Name Organization Name Organization Cherry Family Practice Clackamas Creekside Damascus Estacada Fisher's Landing Gladstone Family Gresham Station Gresham Station IM and FP Hoodland Internal Associates Mt Scott Internal rose Medical Plaza Resilience Sandy Family Practice and Urgent Care Willamette View Mt Tabor Family Medical Group Gresham-Troutdale Family Medical Rosewood Family Health Interventional Pain Northwest Orthopedic Specialists Diabetes and Endocrine MTT RSWD Gastroenterology Associates Northwest Regional Heart Surgical Associates NW Regional Heart & Vascular Electrophysiology rose Urgent Care Portland Arthritis & Bone Care Portland Lung Radiation Rockwood Urgent Care Wound Healing/Hyperbaric Outpatient Rehab Sleep AMC Cascade Internal Judith Kemp MD Tuality Orthopedic, Sports, Spine & Rehabilitation Edmundo Rosales MD Maple Street Tuality Physicians Health First Family Tuality Pulmonary & Marilyn Booth MD Sleep Hicken Medical Mountain View Tuality Outpatient Medical Rehab Hillsboro North Plains Medical Tuality Urgent Care Tuality Virginia Garcia Hillsboro Endocrine Healthcare Primary Memorial Health Care, Orenco s Station Hillsboro Senior Care Westside Medical Gastroenterology Northwest Hillsboro Hematology Sunset Family Health & Westside Neurology Hillsboro Internal Hillsboro Surgical Associates Tuality Obstetrics & Gynecology Tuality/ Cancer Westside Urology Associates East Portland CHO East 2 P a g e

3 Oregon Health & Science University Providers associated with the provider offices in Table 2 can refer and provide services amongst themselves without needing to submit a referral or authorization to HRNW except as outlined by column 3 in Table 3 (marked as ). TABLE 2 Name Organization Name Organization Name Organization Comprehensive Anesthesiology Pain Cornea in Vancouver at CEI Westside in Vancouver Neuro- Ophthalmology at Neuro- Ophthalmology in Vancouver Oculoplastics in Vancouver Retina in Vancouver Adult Perioperative Clackamas DaVita Meridian Davita MLK DaVita Vancouver Devers Eye Fort Vancouver Gresham High Risk Breast/Ovarian Cancer Prevention MPV Adult Perioperative Mt. Hood Acute Pain Service Allergy & al Immunology Anesthesiology Anesthesiology at Anti- Coagulation Arthritis & Rheumatic Disease at Adventist Medical Audiology Bariatric Beaverton Breast Health Cardiology at Cardiothoracic Surgery Cardiothoracic Surgery at Cardiovascular Cardiovascular at for Hematologic Malignancies Faculty Practice for Women s Health for Women s Health Primary Care Colorectal Cancer Risk Management Comprehensive Pain Comprehensive Pain at Gabriel Dermatology Dermatology at Diagnostic Radiology Diagnostic Radiology at Diagnostic Radiology at Cornell West Diagnostic Radiology at Gabriel Diagnostic Radiology at Richmond Diagnostic Radiology at Scappoose East Portland Emergency Emergency FPP Endocrinology Table 2 continues on the next page Family Health at Gabriel Family Health at Marquam Hill Family Health at Scappoose Family at Richmond Family at Richmond Walk-In Family at South Waterfront 3 P a g e

4 Table 2 continuation Name Organization Organization Name Organization Family Palliative Nephrology & at Westside and Comfort Hypertension Primary Care Care Food and Nephrology at Pathology Nutrition at FMC Battle Ground Food and Neurocritical Pathology at Nutrition Department Care Neurocritical Plastic Surgery Gastroenterology Care - Neurology Gastroenterology & Hepatology at Gastrointestinal & General Surgery at General Obstetrics & Gynecology General Surgery Gresham Gynecologic Harold Schnitzer Diabetes Health Health Promotion & Sports Hematology & Medical Hematology & Medical at Hospital Infectious Disease Infectious Disease at In-Patient Cardiovascular Internal at Westside Primary Care Internal & Geriatrics at Marquam Hill Interventional Radiology JBT Health & Wellness Knight Cardiovascular Institute at Beaverton Liver & Pancreas Transplant Molecular & Medical Genetics Neurological Surgery Neurological Surgery at Neurological Surgery Cornell West Neurology Neurology at Neuro- Northwest Portland Hematology Ophthalmology at CEI Ophthalmology at Oral & Maxillofacial Surgery Orthopaedics Orthopaedics at Orthopaedics at Oregon Outpatient Surgery Orthopaedics at Tanasbourne Orthopedics Cornell West Plastic Surgery at Pulmonary & Critical Care Pulmonary at Radiation Radiation at Radiation at Tuality Community Hospital Sleep Disorders Program at the Marriott Southlake Dermatology Sports at Gabriel Surgical Surgical at Trauma Surgery Tualitan Urogynecology Urogynecology at Providence Portland Otolaryngology Urology Otolaryngology at Otolaryngology Hearing Aid Otolaryngology Oral Surgery Outpatient Rehab Palliative Care Urology at Vascular Laboratory Vascular Surgery at Ophthalmology at PNRS Beaverton 4 P a g e

5 PNRS Hollywood Table 2 continuation PNRS Tualatin Tuality/ Cancer PNRS Twin Oaks PNRS Home PNRS Rose Quarter Salmon Creek Important Referral Requirement: Please note that this list is not all-inclusive, review of Policy 700 recommended. received from participating (par) Providers in the same Table can refer amongst themselves as outlined by Table 3 below. Par Providers not in Table 1 or 2 will also follow Table 3 below. For par Specialist Providers further services needed are to be directed to service Providers within the same Table as the PCP. TABLE 3 Non-participating (non-par) Provider or facility always requires prior-auth in all circumstances with the exception of Emergency through ED/Urgent Care : ED to acute in-patient admission for HRNW Humana and UHC members does not require prior authorization. : Elective in-patient procedures require authorization for HRNW Humana and UHC members. : Outpatient services require authorization for HRNW UHC members. Inpatient Admission PCP/SPECIALIST REFERRAL REQUIREMENTS Facility notification to HRNW is required at the time of all admissions. PAR PROVIDERS NOT IN TABLE 1 AND TABLE 2 5 P a g e TABLE 1 OR 2 PAR PROVIDERS Inpatient Elective Procedure Par Facility ED to Inpatient Admission (Discharge planning for inpatient admissions is monitored by Care Mgt.) No No Long Term Acute Care (LTAC) VIBRA Skilled Nursing Facilities Observation Observation Stays No No Durable Medical Equipment (DME) Orthotics, prosthetics, durable medical equipment (see Policy 7507 for DME specifics) Hearing Aids Hearing Aid (Humana) Member to contact TruHearing Hearing Aid (UHC) Member to contact hi HealthInnovations TM Outpatient (Facility/Non-Facility) Outpatient continued Specialist Office Visit by par provider No Ophthalmology Specialist Office Visits, in No office procedures and procedures performed at a par hospital facility do not require PA. (All services performed at an ASC or in a non-par facility require Prior Authorization.) Table 3 continues on the next page No

6 (Facility/Non-Facility) Other Outpatient PCP/SPECIALIST REFERRAL REQUIREMENTS Outpatient Diagnostics or Procedures, including Lab, (Such as: Dexa, ECHO,EEG,EKG, Treadmill, Holter Monitor, Limited Bone Scan, Pulmonary Function Testing, MRI, MRA, Nerve Conduction Study, Vascular Doppler Studies, Audiology, Sleep Studies, etc.) PAR PROVIDERS NOT IN TABLE 1 AND TABLE 2 No TABLE 1 OR 2 PAR PROVIDERS Interventional radiology (pain mgt) No No Pain Management Procedure in clinic or in surgery center PET scans when ordered by a PCP Outpatient Rehab (PT, OT, ST, No No Cardiac) Diabetic Education No Infertility Testing and Treatment Home Health outside of Western Health Resources (Adventist Home Health Portland), Touchmark Home Health, and Tuality Home Health Foot Care Hyperbaric Therapy CHIP (Complete Health Improvement Program) Plastic Surgery/Cosmetic Abdominoplasty, Blepharoplasty, Breast Procedures, Otoplasty, Penile Implant, Rhinoplasty/ Reconstructive Procedures High Cost Injectable High Cost Injectable (The exception is eye injections which do not require preauthorization) Chemotherapy Agents Chemotherapy Agents Radiation / Nuclear / Immuno Therapy Symptom Management Drugs No No PAR AND NON-PAR SEVICES PCP/SPECIALIST REFERRAL IS NOT REQUIRED 1. One post-hospitalization follow-up visit 2. One Emergency Room follow-up visit 3. Post-op visits during global period 4. Chronic kidney dialysis with a diagnosis of End Stage Renal Disease No 6 P a g e