Standing Referrals to a Specialist
Provider Type
- Physicians
- Participating Physician Groups (PPG)
Health Net and its participating physician groups (PPGs) are required to have procedures for members to receive a standing referral to a specialist or specialty care center, including, but not limited to, HIV or AIDS specialists.
Definitions
Standing referral is a referral by the primary care physician (PCP) to a specialist for more than one visit to the specialist, as indicated in a treatment plan, if any, without the PCP having to provide a specific referral for each visit.
Specialty care center is defined as a center that is accredited or designated by an agency of the state or federal government or by a voluntary national health organization as having special expertise in treating the life-threatening disease or condition or degenerative and disabling disease or condition for which it is accredited or designated.
Standing Referral to a Specialist
Health Net and its delegated PPGs provide for a standing referral to a specialist if the member's PCP determines in consultation with the specialist, if appropriate, and medical director (associated with PPG or Health Net) that the member needs continuing care from the specialist as follows:
- If a treatment plan is deemed necessary in the course of care and is approved by Health Net (or the PPG), in consultation with the PCP, specialist and member, the referral is made subject to the terms of the treatment plan.
- A treatment plan may not be necessary if Health Net (or the PPG) approved a current standing referral to a specialist.
- The treatment plan may limit the number of visits to the specialist, limit the period of time that the visits are authorized, or require that the specialist provide the PCP with regular reports on the health care provided to the member.
Prolonged Standing Referral
Health Net and its delegated PPGs provide members with standing referrals for specialized medical care over a prolonged period of time specifically for members who have conditions or diseases that are life-threatening, degenerative or disabling. These members may receive a referral to a specialist or specialty care center with expertise in treating the condition or disease for the purpose of having the specialist coordinate the member's health care as follows:
- If a treatment plan is deemed necessary in the course of care and is approved by Health Net (or the PPG), in consultation with the PCP, specialist, specialty care center, and member, the referral is made, subject to the terms of the treatment plan.
- A treatment plan may not be necessary if Health Net (or the PPG) approves the appropriate referral to a specialist or specialty care center.
- The referral is made if the PCP, in consultation with the member's specialist or specialty care center, and the PPG, determines specialized care is medically necessary for the member.
Time Limits
The determination of a standing referral request is made within three business days from receipt of request by the member or the member's PCP, and all appropriate medical records, and other information necessary is submitted.
Once Health Net or its delegated PPG make the determination, the referral authorization is issued within four business days of the date the proposed treatment plan, if any, is submitted.
Ordinarily PCPs or PPGs do not refer the member to a specialist that is not participating with the PPG or Health Net, unless there is no specialist within the PPG or Health Net's networks that are appropriate to provide treatment to the member, as determined by the member's PCP in consultation with PPG or Health Net's medical director, and documented in the treatment plan. If an out-of-network referral is necessary, benefits are provided at the in-network cost-share.
The PCP and PPG must track and monitor referrals requiring prior authorization. The tracking system must include authorized, denied, deferred, or modified referrals, the timeliness of the referrals, and referrals made to non-participating providers.