General indications for referrals to an Out of Service Area Provider include:

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1 Purpose: To describe Central California Alliance for Health (the Alliance) authorization process for referral of Alliance eligible linked members to Out of Service Area and non-contracted specialty providers. Policy: It is Alliance policy that the referral of an Alliance member to an Out of Service Area Provider, regardless of contract status, requires review and authorization by the Alliance prior to the services being rendered. This does not apply to Alliance Medi- Cal Administrative members. It is also Alliance policy that a referral of an IHSS, or Medi-Cal Access Program ( Other Lines of Business or OLB) member to any noncontracted provider requires Authorization by the Alliance. The Alliance reviews such referrals to ensure that medical criteria are met and that the member is referred to an appropriate provider, prior to providing Authorization for the referral. General indications for referrals to an Out of Service Area Provider include: A. A procedure or other service that is not available through a provider in the Service Area. B. Consultation expertise beyond what is available through a provider in the Service Area. C. Complexity of member s medical needs (i.e. age, co-morbidity), requires service out of area. Exceptions: Exceptions to this Authorization Requirement fall into three categories as listed below: 1. Place of Service Exceptions: a. Skilled Nursing Facility/Long-term Care Facility (SNF/LTC) b. Inpatient/Emergency Room Page 1 of 8

2 Definitions: c. Independent Laboratories d. Dialysis Centers e. Patient s Home f. Ambulance (EMT) 2. Provider Type Exceptions: a. Durable Medical Equipment (DME) Provider b. Pharmacy c. Laboratory (including Genetic Disease Laboratory) d. Hospice e. Home Health f. Portable X-Ray Laboratories (ex. Mobile x-rays) g. Nurse Anesthetists 3. Physician Specialty Type Exceptions: a. Anesthesiology b. Pathology For the purpose of this policy and procedure, the following definitions of key terms are outlined below: Authorization: The process through which a provider requests prior written approval from the Alliance for the provision of certain Non-Emergency, Non-Self-Referral Services to Alliance members. Page 2 of 8

3 Authorization Request: An Alliance form completed and submitted by the Member s provider to request review and approval for a referral of a member to an Out of Service area provider. Authorized Referral: The approved request for referral of an eligible Alliance member to an Out of Service area provider, or of an eligible Other Line of Business (OLB) Member to a non-contracted provider. In Service Area Provider: Any provider based in the Alliance s Service Area, regardless of contract status. Local Out of Service Area Provider: A specialist physician, hospital or allied provider based in an area adjacent to the Service Area, with whom the Alliance has contracted based on an existing referral pattern and claims payment to the provider, and the need for access to the provider s specialty type. Open Network: For Medi-Cal members only, the Alliance has an Open Network policy, allowing PCPs to refer Medi-Cal members to any In Service Area Provider, whether contracted or not, who is willing to see the member, without Authorization by the Alliance. Out of Service Area Provider: A provider not based in the Alliance s Service area, regardless of contract status and not designated by the Alliance as a Local Out of Service Area Provider. Service Area: The Alliance s Medi-Cal Service Area consists of Merced, Monterey, and Santa Cruz Counties. The Alliance s Service Area for IHSS and Medi-Cal Access Program is Santa Cruz and Monterey Counties. Procedures: 1. Authorization Submission Any referral of a member to an Out of Service Area Provider requires Authorization by the Alliance and, the referral of an OLB member to any noncontracted provider requires Authorization by the Alliance. This does not apply to Alliance Medi-Cal Administrative Members. The PCP referring the member to a provider for whom an Authorized referral is required must complete the Authorization Request, and submit it to the Alliance Utilization Page 3 of 8

4 Management Department. Completion of the Authorization Request for Out of Service Area or OLB member non-contracted referral purposes is not required to be expressed at the procedure code level and can be more general (i.e. consultation, work-up, office-based procedures). If a PCP has referred a Member to an In Area or Local Out of Area specialty care physician, and the In Area or Local Out of Area specialty care physician determines that the Member needs another specialist referral, the specialty care physician may complete and submit an Authorization Request seeking Authorization for referral of the Member to another specialist care physician. (See Policy ) Due to the Open Network policy for Medi-Cal members, a PCP may refer a Medi-Cal member to any willing In Service Area provider for specialty care, regardless of contract status, without Authorization from the Alliance. 2. Initial Review Authorizations Submitted Initial review of the Authorization Request is performed by the authorization staff (coordinator/nurse) against the following criteria: a. Determine if this is a service that can be provided within the Service Area. b. If so, determine if the referring provider has attempted to refer within the Service Area and was unable to establish access. If so, refer to the Medical Director for determination. c. Determine if this referral is to a provider that has a contract with the Alliance. If not, determine whether it can be re-directed to a contracted provider. If not, and the Out of Service Area, non-contracted provider is the only option (and the referral meets all other criteria) refer to the Medical Director for determination. In addition, Alliance authorization staff also reviews the referral of a member to an Out of Service Area Provider to determine if there are potential coordination of benefit (COB) issues or other healthcare coverage. Potential emphasis should be placed on: a. CCS for members (especially Medi-Cal under the age of 21). Page 4 of 8

5 b. Medicare (especially referrals for End Stage Renal Disease and renal transplants). If the member does not have Medicare, determine if they are eligible. In these cases, referrals should be made to the appropriate agencies. c. Veterans Administration (VA) Determine if the member is eligible and whether or not they have been getting care under the VA system. 3. Clinical Review of Services of Authorizations Submitted The review of the referral to an Out of Service Area Provider or of an OLB member to a non-contracted provider is reviewed for clinical appropriateness by an authorization nurse. Examples include: a. For specialty consultation for complex cases, was the member seen by a specialist within the Service Area? If so, did the In Service Area specialist agree that the out of area referral and proposed provider are appropriate? b. Has appropriate evaluation been undertaken by a provider within the Service Area, including diagnostic studies? c. Was the request made due to age restrictions (infants or children)? Ensure that is the case with the In Service Area provider of the services. d. Does the member meet the general criteria for the proposed treatment by the Out of Service Area Provider, for example, are there any contraindications, for transplants, weight reduction procedure evaluations or other complex procedures? e. Does member have recent history of care or treatment by Out of Service Area Provider that requires continuity of care? 4. Network Development In the event that there are repeated referrals submitted for services to be provided by an Out of Service Area Provider who is not contracted, Utilization Management (UM) staff will notify Provider Services of the existence of an access issue within the Service Area. In response to those Page 5 of 8

6 References: identified access issues, Provider Services will pursue contractual relationships with both providers in the Service Area and Out of Service Area Providers. In the event that a Member contacts Member Services to request assistance in obtaining services from an Out of Service Area provider, or in the case of an Alliance OLB member, a non-contracted provider, Member Services will educate the Member that the Member s PCP must submit an Authorization Request to the Alliance to have the request approved. In addition, the Member Services staff shall advise the Provider Services Manager or Supervisor as to the Member s PCP for education, and of the requested Out of Service Area or non-contracted provider for possible recruitment. The Alliance determines provider participation in the Local Out of Service Area based on geographic location, history of provision of services to Alliance members, and access within Santa Cruz, Monterey and Merced counties to the specialty type at issue. Only contracted providers within the Service Area and Local Out of Service Area are listed in the Alliance s Provider Directory. All aspects of Alliance Authorization process for review to Out of Service Area and non- contracted specialty providers will adhere to Alliance Health Services / Utilization Management Authorization Policies as described in HS / UM Policies and Procedures Policy Authorization Request Process, including but not limited to authorization request processes such as submission and response timelines, determinations (approvals, denials) and notification, etc. Alliance Policies: Policy Authorization Request Process Policy Referral Consultation Request Process Impacted Departments: Claims Member Services Provider Services Regulatory: Legislative: Contractual: Page 6 of 8

7 DHCS Medi-al Contract Exhibit A, Attachment 18, Provision 9. J DHCS Medi-Cal Contract Exhibit E, Attachment 3, Provision 5 MMCD Policy Letters: NCQA: Supersedes: Other References: Attachments: Exhibit A Authorization Matrix Lines of Business This Policy Applies To Medi-Cal Alliance Care IHSS Medi-Cal Access Program (MCAP) LOB Effective Dates (01/01/1996 present) (07/01/2005 present) (02/01/2009 present) Revision History: Reviewed Revised Date Changes Made By Approved By Date 03/01/ /01/2010 Richard Helmer, MD, CMO Richard Helmer, MD, CMO 08/01/ /01/2010 Richard Helmer, MD, CMO Richard Helmer, MD, CMO 08/01/ /01/2011 Julio Porro, MD, AMDUM Julio Porro, MD, AMDUM 07/25/ /25/2012 Julio Porro, MD, AMDUM Julio Porro, MD, AMDUM 04/02/ /02/2013 Christine Gerbo, RN, UM UMWG Director 05/08/ /08/2013 Mai Chang, Compliance Administrative Assistant Kathy Neal, RN, Chief Health Services Officer 09/16/ /16/2014 Julio Porro, MD, Medical UMWG Director 05/05/ /05/2015 Kathy Dean, RN, UM UMWG Manager Prior Auth 08/15/ /15/2016 Kathy Dean, RN, UM UMWG Manager Prior Auth 05/31/ /20/2017 Kathy Dean, RN UM Manager-Prior Auth UMWG Page 7 of 8

8 Reviewed Date Revised Date Changes Made By Approved By Page 8 of 8