Overview
Provider Type
- Participating Physician Groups (PPG)
Participating physician groups (PPGs) are responsible for providing or coordinating all professional services to members, including care among participating and nonparticipating providers. A referral is required for care that is beyond the primary care physician's (PCP's) or the PPG's scope of practice.
Listed below are examples of services that are referred for specialty consultation. This list provides guidelines and is not intended to be all-inclusive or indicate specific benefit coverage.
- Cardiology - Complicated hypertension (failure to respond or adverse response to conventional therapy).
- Endocrinology - Diabetic complications including retinopathy and nephropathy.
- Gastroenterology - Polyps or other abnormalities.
- Behavioral health services - Diagnosis, treatment and consultation regarding management of clearly emotional issues for which the member or PCP feels the need for consultation (behavioral health services should be coordinated with medical services).
- Neurology - Seizures that are recurrent or refractory to treatment.
- Rheumatology - Collagen vascular diseases depending on the extent and severity of manifestations or complications.
- Pulmonology - Percutaneous lung biopsies.
- Urology/Nephrology - Prostate suspicious for malignancy or obstructive symptoms that may lead to surgical treatment.
- Infectious disease - Diagnosis, treatment and consultation regarding AIDS or human immunodeficiency virus (HIV).
The Centers for Medicare & Medicaid Services (CMS) requires the PPG to do the following when making a referral:
- Transmit necessary information to the provider receiving the referral and vice versa.
- Request information from other treating providers as necessary to provide care.
- Transfer a member's complete medical records to a new provider in a timely manner (when the member chooses a new PCP with the network).
For additional information regarding prior authorizations, refer to the Prior Authorizations topic. For additional information regarding medical records, refer to the Medical Records topic.