Understanding Referrals and Establishing a Medical Home

Transcription

1 Understanding Referrals and Establishing a Medical Home

2 Presentation Agenda Value of Referrals Why Do Referrals Matter? When to Complete a Referral Medical Home Model How to Find a Participating Provider When to Self-Refer How to Complete a Referral Difference Between Pre-Auths and Referrals Provider Relations Specialists 2

3 Value of Referrals Passport s referral requirements are based on the premise that our members are best served with a primary home for care and oversight, thus the Primary Care Provider is responsible for coordinating the member s health care. This ensures the member s PCP is aware of all aspects of the patient s care and can mange their overall health. We want all of our members to have a Medical Home! Our mission is to improve the health and quality of life of our members. 3

4 Patient Centered Medical Home Passport feels that medical home establishment is key to improving the health and quality of life of our members. This concept also allows the member s PCP to maintain knowledge of all aspects of the patient s care. Our goal is for our members to establish a relationship with their PCP before they get sick or have a medical emergency. This will assist the PCP in establishing background information on the patient and will assist the patient in establishing a relationship with the PCP. This will also allow both the PCP and member to focus on preventive care before a medical incident occurs. 4

5 Referrals: Why They Matter Optimize care at appropriate levels and locations Improve coordination to specialty services Supports patient-centered care model Reduces duplication of services and supports care coordination 5

6 When To Complete a Referral PCP referrals are required if a member needs to see a Specialist. Referrals must be made to participating specialists, unless the necessary service is not available from participating Passport Health Plan practitioners. We do not require referrals for Orthopedic or OBGYN services. 6

7 When to Complete a Referral Please refer to the Passport Health Plan Real-Time Provider Directory, or your Navinet service to verify participating providers. members/find-a-doctor/ 7

8 When To Complete a Referral For referrals to a non-participating specialist, the PCP must request prior authorization from Passport Health Plan s Utilization Management department. The PCP should verify that the specialist accepts Kentucky Medicaid. Passport Utilization Management:

9 When to Complete a Referral Referrals are required for a visit to an Urgent Care/Walk-in Clinic if the visit takes place during regular business hours (before 4 PM, Monday-Friday). If it is Saturday, Sunday, a national holiday, or a weekday after 4 p.m., Passport Health Plan members may go to specified urgent care centers without a referral. 9

10 Self-Referrals Member s may self-refer in specific instances. Examples 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 authorization). Maternity care Immunizations for members younger than 21 years of age. Chiropractic services up to 26 visits. GYN services, including Pap smears and mammograms. Orthopedic care For more specific information, and a complete list, refer to Section of the Passport Provider s Manual 10

11 How to Complete a Referral Passport Health Plan currently offers two options for the initiation and submission of referrals. While paper referral forms remain an option at this time, providers are strongly encouraged to use the electronic submission process available at or by logging onto NaviNet at 11

12 Paper Referrals Complete Member and Provider Information. Use Passport Provider and Group ID s. Ensure Specialist is in network, then complete Specialist information. Complete Diagnosis information, and number of visits approved. Sign and send to Passport, Specialist and Patient. 12

13 Completed referral forms should be distributed as follows: Copy 1 - Send to Passport Health Plan immediately at: Passport Health Plan P.O. Box 7114 London, KY Paper Referrals Copy 2 - Specialist copy. Copy 3 - Patient s copy. Copy 4 - PCP s copy (to be placed in member s chart). 13

14 Paper Referrals Responsibilities of the specialist or consulting practitioner: Retain copy of referral form for the member s file. Send a copy of the consult report to the PCP. 14

15 Electronic Referrals Referrals initiated via Navinet are automatically transmitted to Passport. For specific instructions on how to register and utilize Navinet, refer to the Navinet webinar on our website, or contact your Passport Provider Relations Representative. 15

16 Electronic Referral Submission Log onto your Navinet account and click the Referral Submission link. 16

17 Electronic Referral Submission Select Search Type Enter Patient Information 17

18 Electronic Referral Submission Enter Referred FROM Provider Information Enter Referred TO Provider Information 18

19 Electronic Referral Submission Enter Diagnosis Information and add the Diagnosis Code Select service type and Referral Date Select number of visits Select a lab from the pull-down menu 19

20 Electronic Referral Submission Review the Referral Submission Verification for accuracy. Click submit to verify the form and continue to the Referral Submission Response screen. 20

21 Electronic Referral Submission Clicking Submit verifies the form and takes you to the Referral Submission Response screen. Please note that the referral authorization number that is generated when completing an online referral via Navinet is only an internal confirmation number for the provider that the referral was submitted, and is not an actual referral number. There are no referral numbers given to providers by Passport as they cannot be generated when completing a paper referral. 21

22 Electronic Referral Inquiry Log onto your Navinet account and click the Referral Inquiry link. 22

23 Electronic Referral Inquiry Select Search Type Select if you are inquiring on behalf of the referred to provider or the referring provider Select a provider group Select Member Search Type and enter all required information 23

24 Pre-Authorizations vs. Referrals These are two separate processes! Pre-authorizations are a process to determine medical necessity of a particular medical service. Referrals are a recommendation by which a primary care provider (PCP) sends a member to another provider for services that are typically outside the PCP s scope of practice. 24

25 Pre-Authorizations vs. Referrals For a complete list of services that require Pre- Authorization, refer to the Passport Provider Manual Section 5.3. Pre-Auth Inquiries (Medical), call Utilization Management (877) Pre-Auth Inquiries (Behavioral Health), call Behavioral Health Hotline (855)

26 Provider Relations Specialists: Regions 1, 2, 4 Lori Kent Region office Lori.kent@passporthealthplan.com Amber Henderson Region office Amber.henderson@passporthealthplan.com Beth Goodin Region office Beth.goodin@passporthealthplan.com 26

27 Provider Relations Specialists: Region 3 Becky Murphy office Becky.murphy@passporthealthplan.com Dell Fraze office Dell.fraze@passporthealthplan.com Courtney Kelly office Courtney.kelly@passporthealthplan.com 27

28 Provider Relations Specialists: Region 3 Sandy King office Sandy.king@passporthealthplan.com 28

29 Provider Relations Specialists Regions 4, 5, 6 Lucy Howard office Lucy.howard@passporthealthplan.com Jennifer Cahill office Jennifer.cahill@passporthealthplan.com Donna Moor office Donna.moor@passporthealthplan.com 29

30 Provider Relations Specialists Regions 5, 7, 8 Angela McGraw office Angela.mcgraw@passporthealthplan.com Terry Orick office Terry.orick@passporthealthplan.com Becky Barbera office Becky.barbera@passporthealthplan.com 30

31 Provider Relations Specialists Jack Boles office Robert Hamilton office Herlon Robinson office 31

32 Provider Relations Specialists Noel Harilson office 32

33 Troubleshooting In the event a member has not been assigned a PCP, and is new to the Plan (in the first 30 days after enrollment), a participating specialist provider may contact the UM department at to request authorization of a one-time visit without a referral. Provider Services

34 Troubleshooting Passport has developed a new ER Referral Policy. If a member has been in the emergency room or discharged from the hospital in the last 30 days, and requires an urgent referral to a specialist., a one-time visit may be authorized to a Specialist. To access this referral, you may call Utilization Management at