Provider Manual—Commercial Plans

Referrals

Updates: Section 2 Retroactive Referrals Policy Change revised January 2019.

Quick links:

  1. Referral Policy
  2. Retroactive Referrals Policy Change
  3. Referral Procedure
  4. Referral Management Entities
  5. Out-of-Panel Referrals
  6. Referral Not Required
    6.1 List of Services  
  7. Referrals That Are Not Approved


1 Referral Policy

The member’s primary care practitioner (PCP) will be responsible for routine medical care and will coordinate any required specialty care. The PCP, or the PCP call share partner, is responsible for requesting a referral for specialty care services.

Referral requests are made by the PCP to PacificSource Health Plans Health Service department or (if applicable) to a managed care/referral coordinator. Referral services may be provided by:

  • Physician and/or provider groups contracted with PacificSource
  • A subcontracted entity delegated by PacificSource, or a physician and/or provider group
  • PacificSource Health Plans

The PacificSource Health Services department either approves or does not allow referrals based on established criteria. If the referral reviewer is not able to make a decision, further evaluation will be made by a medical director and/or review committee.

PacificSource benefit plans that have PCP and referral requirements stipulate all specialist services (except those listed as “Referral Not Required”) must have a PCP referral, and must receive authorization from either the PacificSource Health Services department or the managed care/referral entity.

Once you are logged in to InTouch, simply click “Submit an Authorization.” Referrals may be approved immediately through InTouch. 

Notification process: We communicate our referral decisions in writing to the member, the requesting provider, and the specialist. Notices will be faxed or mailed within two working days after we receive the referral request.

Please note: Referral authorization does not imply that services will be covered by the member’s policy. In addition to a referral, the member’s plan may require a preauthorization for the specific service. It is important that the member contact the PacificSource Customer Service department for benefit information prior to being seen by the specialist.

See our Referral Frequently Asked Questions (Oregon) document.



2 Retroactive Referrals Policy Change

We realize there are sometimes instances when a referral may not have been in place prior to services being rendered; this should be the exception and not the rule. Retroactive referrals may be eligible up to 90 days of the date of service if determined to be medically necessary and appropriate. Please verify if this is available for your patient through our Customer Service team, as this is not available on all plans.



3 Referral Procedure

When the services of a specialist are necessary, the primary care practitioner (PCP) requests a referral to a panel specialist through the Health Services department or managed care office. The referral coordinator issues approval or non approval for the referral and communicates the decision to the member, PCP, and specialist. PacificSource requires the following information for processing referrals:

  • Member name and ID number
  • Ordering provider information (PCP) and contact information
  • Treating provider (or facility name) and contact information
  • Diagnosis code(s)
  • Start date of request

With the exception of Pain Management referrals, we no longer request a specific number of visits on the referral form. Referral requests up to a total of six visits may be granted automatic approval.

Surgery is counted as one of the referral’s authorized visits, regardless of the place of service. Approved specialist services occurring after the procedure’s global period, but within the time period requested, are still available to the member.

The following restrictions apply:

  • Referrals must be made to a specialist on the appropriate panel, unless the specialty services are not available on that panel.
  • Referrals become void if the member changes his/her PCP.
  • Referrals should be made for covered diagnoses only.
  • Retro referrals may be accepted within 90 days from the date of service. Please verify for your patient through Customer Service, as this is not available for all health plans.

As long as the referral request is submitted on or prior to the treatment date and the referral is approved, the effective date requested on the referral will be granted.

If you see a patient prior to receiving the referral determination, you may want to have the patient sign a liability waiver for the specific services and/or procedures rendered, should the referral request be denied. The member’s PCP will need to submit a retro referral request within 90 days of the date of service.

Please call Customer Service for benefit information. If you have other questions or concerns, contact the Health Services department by phone at (541) 684-5584 or toll-free at (888) 691-8209, or by email at healthservices@pacificsource.com.



4 Referral Management Entities

Each physician or provider who is contracted for products with referral requirements needs to request referrals through a designated referral authorization entity. The referral management or authorization entity may be a department in a large clinic, an IPA office that represents the physicians and/or providers, or an independent company. In addition, physicians and providers may choose to have PacificSource perform the referral review process.

Referral operations are typically comprised of a managed care coordinator, a medical director, and a committee. The coordinator receives the referral authorization request and, based on an established set of criteria, evaluates the request for approval. If the coordinator is unable to make a determination, the request is referred to the Medical Director. Referral determinations are communicated to PacificSource for appropriate data entry into the claims system.

Know who manages your referrals. Check your provider contract provision regarding referrals, or contact our Provider Network Management by phone at (541) 684-5580 or (800) 624-6052, ext. 2580, or by email at providernet@pacificsource.com.



5 Out-of-panel Referrals

The PCP is responsible for referring the member to a panel physician or provider; however, members occasionally require care that is not available within the panel. When this happens, the PCP may request a referral to an out-of-panel physician or provider.

When the delegate’s referral management coordinator receives an out-of-panel referral, the request and all the pertinent information are forwarded to the PacificSource Health Services department for review by the referral coordinator. The request is evaluated for medical necessity, contract benefit, and/or continuity of care.

The PacificSource referral coordinator will investigate and take under consideration whether or not the service is available from a panel provider while keeping the patient’s care a primary consideration.

When PacificSource Health Services department receives an out-of-panel referral from a managed care office, the following procedures apply:

  • The referral intake person ensures that the referral management coordinator is aware that the physician or provider is out-of-panel.
  • The referral coordinator may contact the delegate or PCP to discuss the referral. The goal is to direct the member to a contracted physician or provider.
  • Depending on the results of the coordinator’s investigation, the approval or nonapproval of the requested service will be determined.
  • PacificSource will inform the delegate’s office of the determination by phone if the request is not approved.
  • PacificSource will then communicate the determination via fax or mail to the provider, member, delegate entity, and specialist and will include appeal information.

If your patient requires services not available within the panel or network, please contact our Health Services department by phone at (541) 684-5584 or toll-free at (888) 691-8209, or by email at healthservices@pacificsource.com.



6 Referral Not Required

6.1 List of Services

The following services do not require a referral. For a more complete list, please contact Customer Service as these vary from plan to plan. 

  • A declaration of disaster or emergency
  • Ambulance
  • Anesthesia
  • Assistant surgeon
  • Emergency care
  • Well baby/well child care.
  • Women’s health: Members may self-refer for pregnancy care and annual gynecological (GYN) examinations and contraceptive care. In addition, any medically necessary follow-up visits resulting from the annual exam do not require referral when performed within three months of the annual exam.




7 Referrals That Are Not Approved

When Health Services or the delegated managed care entity does not approve a referral request, the PCP, specialist, and member are notified by mail or fax. It is the PCP’s responsibility to discuss other options with the member. Appeal rights will be included with the determination, and the PCP or member may appeal the decision in writing by submitting supporting documentation for re-evaluation of the request.

Referrals may not be approved for reasons including, but not limited to, the following:

  • Not medically necessary
  • Not a covered benefit
  • Request for service/visit is included in the global service
  • Service is available within the provider panel
  • Member has self-referred

Please see “ Appeals” under the Physicians and Providers section for further review of a referral that was not approved.

PCPs are expected to discuss referrals that are not approved with their patients. Members have the right to appeal through PacificSource.

 

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Last updated 1/22/2019