SECTION F REFERRAL AND PRIOR AUTHORIZATION PROCESS

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1 OVERVIEW Harbr Advantage members may require services that g beynd the scpe f their PCP. ccurs, the PCP refers the member t an apprpriate specialist. When this Please be sure t verify member s eligibility and refer t the apprpriate prir authrizatin guidelines fr prir authrizatin requirements. Yu may cntact Netwrk Management fr a cpy t be sent t yur practice r g t ur website at Authrizatins are valid fr 120 days as lng as the member retains eligibility with Harbr Advantage. If yu are unable t schedule the cnsult with the member within the apprpriate timeframes referenced abve, please cntact the Prir Authrizatin Department and request t have the authrizatin extended prir t rendering the service. STANDARD AUTHORIZATION REQUESTS A rutine request is nn-urgent and will be respnded t within 14 calendar days r sner upn receipt f a request. Please supply all supprtive dcumentatin t assist in rapid prcessing f yur request. When requesting multiple services fr a member, please fax each request separately. Bundled requests cause delays in prcessing as the fax requires unbundling. Determinatins will be faxed t the requesting prvider within 1 business day f rendering a determinatin. EXPEDITED AUTHORIZATION REQUESTS Harbr Advantage is t prcess expedited requests within 3 calendar days r sner f receipt f all supprtive dcumentatin. Determinatins will be faxed t the requesting prvider within 1 calendar day f rendering a determinatin. "Expedited" request is defined as "when using the standard timeframe culd seriusly jepardize the member s life r health r ability t attain, maintain r regain maximum functining". Please remember nt t use "expedited" fr the cnvenience f the member r the physician. In cases when the request des nt meet the "expedited" criteria, but is time sensitive, the Plan will attempt t prcess the request in the timeframe requested." FORMULARY Please refer t Frmulary in Sectin I fr prir authrizatin infrmatin. REFERRAL PROCESS FROM PCP TO SPECIALIST When the PCP refers the member t an apprpriate specialty care prvider (specialist): PCP selects a cntracted specialist. Refer t the apprpriate prir authrizatin guidelines t determine if an authrizatin is required fr that specialty. If prir authrizatin is NOT required fr the referral, the prvider may fax the cmpleted prir authrizatin frm alng with pertinent dcumentatin, cntact name and phne number directly t the cntracted specialist and ntify the member that they may schedule an appintment.

2 If prir authrizatin is required, fax the cmpleted prir authrizatin frm t the prir authrizatin department. Please include ICD-9 and CPT cde(s), pertinent dcumentatin, and a cntact name and phne and fax numbers with area cde. If the request is apprved, an authrizatin is issued fr a cnsult and same day treatment. Once authrizatin is btained, fax the prir authrizatin frm with the authrizatin number t the cntracted Specialist and ntify the member that they may schedule an appintment. NOTE: It is the respnsibility f the specialist t verify member eligibility at each appintment, prir t rendering services. Services will nt be reimbursed if a member is nt eligible n the date f service. Specialists must refer t the prir authrizatin guideline t determine what services may be rendered withut btaining prir authrizatin. If fllw-up visits are needed, refer t the prir authrizatin guideline t determine if an authrizatin is required fr additinal visits t the selected specialty. If prir authrizatin is NOT required, the specialist may prceed with scheduling fllw-up visits t see the member. If prir authrizatin is required, the specialist r PCP must request a prir authrizatin. A legible cnsult nte r clearly written dcumentatin must als be attached t supprt the request, alng with apprpriate ICD-9 and CPT cde(s) and a cntact name and phne number with area cde. The specialist r PCP may request an authrizatin fr the entire treatment plan as lng as the cnsultatin ntes have been submitted. If surgery r a special prcedure is required, the specialist r PCP must request a prir authrizatin using the prir authrizatin frm. A legible cnsult nte r clearly written dcumentatin must als be attached t supprt the request, alng with apprpriate ICD-9 and CPT cde(s), the name f the cntracted facility where services will be rendered and a cntact name and phne number with area cde. Prir authrizatin requests fr surgery must be cmpleted at least 14 days prir t the date f the surgery unless it is an emergent situatin. Authrizatins fr surgery are valid fr 120 days, after which time the authrizatin must be extended. Cpies f the cnsultatin and any fllw-up ntes must be prvided t the member s PCP. REFERRAL PROCESS FROM SPECIALIST TO SPECIALIST Shuld a specialist need t refer a member t anther specialist, it is nt necessary fr the member t be physically referred back t the PCP as lng as the PCP has been infrmed f the impending referral. The referring specialist must refer t the apprpriate prir authrizatin guidelines t determine if an authrizatin is required fr the needed specialty. If a prir authrizatin is required, the prir authrizatin frm shuld be cmpleted and submitted as utlined abve. REFERRAL PROCESS FOR ANCILLARY PROVIDERS The referring prvider shuld take nte f the fllwing:

3 Durable Medical Equipment Cvered durable medical equipment (DME) must be medically necessary and prescribed by a PCP r specialist. DME can be btained by cntacting the cntracted DME prvider directly. If additinal assistance is needed, please cntact the prir authrizatin department. Please include the fllwing infrmatin when submitting a request fr DME: Amunt, type and size f equipment desired including HCPC cde Member infrmatin Name Member I.D. Number Weight Address Phne number Diagnses Recent bld gases if the request is fr xygen Cmpleted and signed Certificate f Medical Necessity The fllwing limitatins shall apply: Reasnable repairs r adjustments f purchased medical equipment are cvered when necessary t make the equipment serviceable and when the cst f repair is less than the cst f rental r purchase f anther unit. The equipment must be cnsidered medically necessary by Harbr Advantage. The rental f such equipment shall terminate n later than the end f the mnth in which the member n lnger needs the medical equipment as certified by the authrized prvider. Or when the member is n lnger eligible r enrlled with Harbr Advantage (except during transitins f care as specified by the Plan s Medical Directr). Ntes: SVN machines, standard wheelchairs, standard walkers, and crutches can be btained by directly calling Harbr Advantage s cntracted DME prvider withut an authrizatin. Fr ther DME items, fax a cmpleted service request frm, dcumentatin t supprt the request, and the prescriptin t the DME vendr. A cmpleted and signed Certificate f Medical Necessity is required fr certain items such as xygen and semi-electric wheelchairs. Hme Health Care and Infusin Care Select a cntracted prvider frm the nline referral directry. Call the intake department at a cntracted hme health care agency. Orthtics and Prsthetics Orthtic and prsthetic services are cvered when medically indicated and prescribed by a cntracted prvider. When referring a member fr rthtic/prsthetic services, the prvider's ffice must submit a prir authrizatin alng with supprting dcumentatin and apprpriate HCPC cde. Once apprved, the rthtic/prsthetic prvider will cntact the member fr fitting and delivery.

4 Outpatient Labratry Services Cmplete a labratry requisitin and direct the member t the cntracted labratry drawing site. If drawing a specimen in the ffice, cntact the cntracted labratry fr pick up. Labratry services must be dne at a cntracted lab facility with the exceptin f the fllwing cdes that fee-fr-service PCPs and specialists may perfrm in his/her ffice. In-Office Lab Test List (Fee-Fr-Service Prvider): Bld draw Bld draw Urinalysis w/micrscpy Urinalysis w/ micrscpy, nn-autmated Urinalysis w/ micrscpy; autmated Urine pregnancy test Glucse, bld by Glucse Mnitring Device Bld Cunt; Spun Hematcrit Bld Cunt; Bld Smear; Micrscpic exam w/ Manual Differential WBC Cunt (Fr Onclgist Only) Bld Cunt; Bld Smear; Micrscpic exam w/ Manual Differential WBC Cunt (Fr Onclgist Only) Autmated Hemgram (Fr Onclgist Only) Hemgram and Platelet Cunt (Fr Onclgist Only) Reticulcyte Cunt (Fr Onclgist Only) Strep Quick Test (particle agglutinatin; screen, each antibdy) Ccci Intradermal Test TB Intradermal Test Smear, Wet Munt Influenza Assay w/ Direct Optical Observatin Streptcccus, grup A w/ Direct Optical Observatin Bdy Fluid Cell Cunt (Fr Onclgist Only) Radilgy Services Select the cntracted site fr the service frm the nline referral directry. Call a cntracted prvider t schedule an appintment date and time. It is the respnsibility f the imaging service prvider t verify member eligibility with the Harbr Advantage Member Services department prir t rendering services. Rehabilitatin Services (PT/ST/OT) If prvided by a cntracted prvider, physical therapy (PT), speech therapy (ST) and ccupatinal therapy (OT) fr an acute episde may be referred fr an initial evaluatin withut prir authrizatin. Fllwing the initial evaluatin, the therapy prvider is respnsible fr referring t the apprpriate prir authrizatin guidelines fr requirements n btaining prir authrizatin fr the treatment plan.

5 HOSPITAL ADMISSIONS Emergency Department Emergency rm visits d nt require a fax ntificatin t the health plan. If the member is admitted as an inpatient, fax ntificatin is required within twenty-fur (24) hurs f the admissin. Infrmatin must include: Member Name Member I.D. Number Date f Birth Type f Service Facility's Name Diagnsis Pertinent health status infrmatin Inpatient Admissins thrugh the Emergency Department Shuld the member require admissin t the hspital, the member s PCP r hspitalist must be called and the call dcumented n the ER recrd. Hspital admissin ntificatins must be faxed within 24 hurs f admissin. Elective Inpatient and Outpatient Admissins Elective and emergency hspital admissins that are initiated by any prvider will be subject t the facility's admissin screening prcedures. The facility is required t fax ntificatin fr admissin t (313) within 24 hurs f the admissin. The cntracted prvider must use the hspital s reference number fr an emergency hspital admissin. An elective hspital admissin initiated by the PCP r specialist requires a prir authrizatin prir t the scheduling f the admissin at a cntracted facility. Prir authrizatin frms shuld be faxed t the prir authrizatin department. The prir authrizatin department will fax the authrizatin t the requesting prvider upn apprval. Harbr Advantage als requires a fax ntificatin frm the facility fr ntificatin f the inpatient admissin f a member within 24 hurs f the admissin. SKILLED NURSING FACILITY ADMISSIONS All admissins t a skilled nursing facility (SNF) must be prir-authrized by the Harbr Advantage Hspital Cncurrent Review Nurse prir t admissin. Fr Harbr Advantage members, the level f service and number f cvered days in the SNF is based upn the medical necessity f the cnditin as determined by Harbr Advantage. MEMBER TRANSFERS Harbr Advantage may transfer members t a Plan-cntracted facility as sn as it is medically safe t d s. The transfer will take place as sn as bth the relinquishing and receiving physicians agree that a medically safe transfer is pssible. If a safe transfer can take place, the physician attending/discharging and the receiving physician must be in cntact with each ther regarding the medical treatment plan and cntinuity f care. The attending

6 physician must agree t release the member and the new physician must agree t accept the member. Harbr Advantage s Medical Directr mediates bjectins t the transfer by the attending physician r Plan-assigned physician. Families/significant thers wh refuse a medically safe transfer shall be infrmed that they may be financially respnsible fr the cntinued stay in a nn-cntracted facility. The member and/r authrized representative can invke their right t appeal in accrdance with CMS Regulatins and Guidelines.