Provider Manual Section 6.0 Referrals
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1 Provider Manual Section 6.0 Referrals Table of Contents 6.1 Enrollee Self-Referral (Direct Access) 6.2 Referral Requirements 6.3 Distribution of Referrals Page 61 of 124
2 6.0 Referrals 6.1 Enrollee Self-Referral (Direct Access) There are a number of services covered by Lighthouse for which enrollees can make appointments with participating Lighthouse providers without referrals from their PCP. These include: Routine vision care services, including diabetic retinal exams and the fitting of eyeglasses provided by ophthalmologists, optometrist, and opticians; Routine dental services, and oral surgery services and evaluations by orthodontists and prosthodontists (orthodontic and prosthodontic services require prior authorization); Maternity care; Immunizations for all enrollees; Screening, evaluation, and treatment for sexually transmitted diseases; Screening, evaluation, and treatment for tuberculosis; Chiropractic Authorization is required; Testing for HIV, HIV-related conditions, and other communicable diseases; GYN services, including pap smears and mammograms; Voluntary Family Planning in accordance with federal and state laws and judicial opinion* Routine outpatient behavioral health services do not require a PCP referral. (See section 15 (Authorization Procedures and Requirements) for those requiring prior authorization); Substance abuse treatment; Enrollees with special health care needs are defined as enrollees who face daily physical, behavioral, or environmental challenges that place their health and ability to fully function in society at risk. This includes individuals with intellectual disabilities or related conditions; individuals with serious chronic illnesses, such as human immunodeficiency virus (HIV), schizophrenia, or degenerative neurological disorders; individuals with disabilities resulting from many years of chronic illness such as arthritis, emphysema, or diabetes; children/adolescents and adults with certain environmental risk factors such as homelessness or family problems that lead to the need for placement in foster care; and all enrollees in LTC Managed Care Plans. *NOTE: For family planning services, enrollees may self-refer to any participating Medicaid provider. For more information, please refer to Section 13, Family Planning. Page 62 of 124
3 6.1.1 Additional Referral Exceptions In addition to the direct access services outlined above, enrollees do not need referrals for the following: Diabetic retinal exams; OB/GYN services; and Perinatologists/geneticists. The following referral exceptions also apply: One lifetime referral is required for each transplant; Referrals to specialists are not required for children in foster care or living in out-ofhome placements; Referrals are not required for participating orthopedists; and Referrals are not required for enrollees with Medicare or Tricare as the primary payer. 6.2 Referral Requirements Lighthouse s referral requirements are based on the premise that our enrollees are best served with a primary home for care and oversight, thus the PCP is responsible for coordinating the enrollee s health care. Except as outlined in Sections 6.1 and 6.1.1, if the enrollee needs to see a specialist, the PCP will complete and issue a referral to the specialist.* PCP referrals can only be made to participating specialists, unless the necessary service is not available from participating Lighthouse practitioners; Prior approval by UM is not required for referrals to participating providers, but a referral must be noted in the enrollee s medical record; If a PCP wants to refer an enrollee to a non-participating provider, the PCP must request a prior authorization from Lighthouse s UM department. The PCP should also verify that the specialist accepts Florida Medicaid; Requests for retrospective review of inpatient services provided by nonparticipating providers require review and authorization by UM; Cases requiring follow-up visits or treatment by nonparticipating providers that were not prior authorized must be reviewed by UM; Referrals for consultation, diagnostic studies, and treatment are valid for six (6) months unless otherwise specified by the enrollee s PCP; The PCP may also designate a visit limit if preferred with a specialty referral; and Lighthouse enrollees have the right to a second opinion. *An exception occurs for newly-enrolled enrollees (in the first thirty (30) days after enrollment) who have not yet selected or been assigned to a PCP. Under these Page 63 of 124
4 circumstances, if an enrollee requires specialist care, a participating specialist provider may contact the UM department to request authorization of a one-time visit without a referral. NOTE: Please refer to the Lighthouse Provider Directory on to verify participating providers. Occasionally, a referral will be made following a telephone conversation between the enrollee and the PCP who determines the need for specialty care. When a verbal referral is made, it is the PCP s responsibility to follow up with either an electronic or a paper referral. Enrollees may not obtain a referral to a specialist when the PCP can perform the services. 6.3 Distribution of Referrals Lighthouse currently offers two (2) options for the initiation and submission of referrals. While paper referral forms can be located at providers are strongly encouraged to use the electronic submission process on Lighthouse s Provider Portal at Distribution of forms is based on the selected method and detailed below: Electronic o Referrals initiated via the web-based program are automatically transmitted to Lighthouse. PCPs should print three (3) copies of the referral to be distributed as follows: o Specialist copy (to be sent with enrollee or mailed to a specialist); o Enrollee s copy; and o PCP s copy (to be placed in enrollee s chart). Paper o Completed referral forms should be distributed as follows: o Copy 1 - Send to Lighthouse immediately at Lighthouse Health PO BOX Eagan, MN o Copy 2 - Specialist copy (to be sent with enrollee or mailed to specialist); o Copy 3 Enrollee s copy; and o Copy 4 - PCP s copy (to be placed in enrollee s chart). Fax o Referrals initiated via Facsimile are automatically uploaded to our clinical and are automatically transmitted to Lighthouse. PCPs should print three (3) copies of the referral to be distributed as follows: Page 64 of 124
5 o Specialist copy (to be sent with enrollee or mailed to a specialist); o Enrollee s copy; and o PCP s copy (to be placed in enrollee s chart). Responsibilities of the specialist or the consulting provider: Retain a copy of the referral form for the enrollee s file; and Send a copy of the consult report to the PCP. Page 65 of 124
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UNIVERSITY OF MICHIGAN BZK Effective Date: 01/01/2018
UNIVERSITY OF MICHIGAN 68712000 0070051870000-06BZK Effective Date: 01/01/2018 This is intended as an easy-to-read summary and provides only a general overview of your benefits. It is not a contract. Additional
Telemedicine services $0 copay Not applicable Primary care provider (PCP) CYD/Coinsurance CYD/Coinsurance CYD/Coinsurance CYD/Coinsurance
Calendar Year Deductible (CYD) 2 Plan includes an embedded individual deductible provision. An embedded deductible combines individual and family deductibles in $4,000 Single / $8,000 Family $12,000 Single
Summary of Benefits Silver 70 HMO Trio
Blue Shield of California is an independent member of the Blue Shield Association Summary of Benefits Silver 70 HMO Trio Individual and Family Plan HMO Benefit Plan This Summary of Benefits shows the amount