IT IS THE RESPONSIBILITY OF THE PRIMARY CARE PHYSICIAN TO ENSURE THE REFERRALS ARE SENT TO PCHP. IF A CLAIM IS RECEIVED AND THERE IS NO REFERRAL IN THE SYSTEM, THE CLAIM WILL BE REJECTED.
Due to potential changes in Member eligibility, the Referral Request Form should generally be issued within the same month that the services are rendered (exceptions would include prenatal care and dialysis).
PCP’s should also verify that a member is assigned to them prior to the issuance of a referral. If a referral is issued for a member not assigned to the PCP, it will be charged to their referral fund.
RETROACTIVE CONSULTATION REQUEST FORMS:
The PCP may issue a retroactive referral to a specialist or other provider under limited circumstances. If a situation arises where the Member received medical treatment PRIOR to obtaining the PCP Consultation Request Form; and the PCP determines that the treatment rendered was reasonable and necessary; and the reason for not obtaining prior authorization was valid, a retroactive referral may be issued. A PCP has the right to refuse to issue a retroactive referral. When a retro referral is issued, the PCP, or his/her designee should complete the referral form as usual, indicating the date the services were actually rendered. If the referral is not identified as a retroactive referral, it will be entered into the system as of the date received. Retro referrals should not be issued past 60 days.
PCHP PRIOR AUTHORIZATION:
Services Requiring Pre-Approval by ProCare Health Plan
The following services require Pre-Approval from ProCare Health Plan. Depending on the circumstance they may require a referral and prescription from the PCP. If there is a question regarding the need for an authorization please contact the Utilization Department at 313-267-0314. Services / equipment issued without an authorization number from ProCare Health Plan will be denied upon billing.
- Elective Inpatient Admissions
- Bariatric Surgery
- Durable Medical Equipment
- Medical Supplies
- Prosthetics and Orthotics
- Home Oxygen and Related Supplies
- Home Infusion Care
- Home Health Care - RN, PT, OT
- Hospice Care
- Hearing Aids
- Nursing Home Care (Non-Custodial)
- Transplant Services
- Any service not covered by Medicaid
- All out-of-network services (This includes out of state referrals)
HOW TO OBTAIN PLAN APPROVAL:
Pre-approval from the Plan for the above services must be obtained by the Member’s PCP. (The only exception is for services following an inpatient admission. Those services and referrals will be authorized by Pro Care Utilization / Case Management nurses.) Referrals must be issued (along with all pertinent medical documentation ) and sent to the Plan. When a request is approved, the Plan authorization will be issued to the provider of services and the PCP. All such providers requesting direct authorization from the Plan will be referred to the Member’s PCP, or the Plan will contact the Member’s PCP for information prior to issuing the authorization. Elective procedures and admissions must be reported to the Plan 72 hours in advance. Failure to do so may result in unnecessary delays or cancellations of procedures. Requests should be faxed to (313-921-0841)
HOSPITAL ADMISSIONS:
When the PCP has a Member requiring an elective admission, the PCP must contact PCHP’s Utilization Department. The contact can be by telephone or fax. The PCP or his/her designee should provide the following information:
- Member’s Name and Recipient ID Number
- Name of Provider Being Referred to
- Address/Telephone of Referred Provider
- Diagnosis and Diagnosis Code
- Specific services being requested, including procedure code and quantity if applicable.
- Admission/Appointment Date
The request will be reviewed by the Plan’s UR staff and, based on the information provided; the Utilization Services staff will give one of the following responses:
- Notify PCP that the service is authorized via fax.
- Request additional information
- Refer the request for Medical Director’s review and approval.
- Issue a denial (if done by the Medical Director) with reason for denial.
If requested service is approved, the Utilization Management staff member will issue a Plan authorization number to the hospital on the day of service. ProCare Health Plan does not issue authorization numbers prospectively. Elective admissions that are not pre-approved will be denied.
For the PCP’s convenience, requests for Plan precertification may be faxed to the Plan.
EMERGENCY TREATMENT AND EMERGENCY INPATIENT ADMISSIONS:
Emergency services, for screening and stabilization where a prudent layperson, acting reasonably, would have believed that an emergency medical condition existed, do not need prior approval from the plan. When emergency services are authorized by an authorized organization representative, they do not require authorization.
Emergency admissions require an authorization number from PCHP. This number is obtained by the hospital the next business day after the admission. Once PCHP is notified and the admission is approved, based on all information relevant to the member’s care and following the admission policy, the PCP is notified of the admission via fax. PCHP uses nationally accepted criteria as a guideline for authorizing admissions as well as accepted local standards of treatment and medical knowledge. When questions regarding medical necessity for admissions arise, an expert panel of board certified physicians may be contacted. PCHP does not give financial incentives for the denial of any type of service by the PCP or physician advisors. Financial incentives for decision makers do not encourage decisions that result in underutilization. Decisions are based solely on the appropriateness of care and service and existence of coverage.
AMBULATORY SURGERY (Same Day Surgery)
Pre-approval from the Plan for services must be obtained by the Member’s PCP. Plan authorizations will be issued directly to the Provider of service. All such providers requesting direct authorization from the Plan will be referred to the Member’s PCP, or the Plan will contact the Member’s PCP for approval prior to issuing the authorization. Elective procedures and admissions must be reported to the Plan 72 hours in advance. Failure to do so may result in unnecessary delays or cancellations of procedures.
VISION SERVICES AUTHORIZATION:
PCHP members may access vision services directly. Vision services include eye examination (refraction), lenses and frames. Members seeking vision services should be directed by the PCP or the Plan to a Plan contracted vision provider. A list of contracted Vision Providers is available to members and providers. The vision providers have been instructed to contact the Plan’s Customer Services department directly for authorization. Referrals for medical eye care (ophthalmology) require the issuance of a Pro Care Referral form from the PCP.
SERVICES THAT DO NOT REQUIRE REFERRAL FORM OR PLAN PRECERTIFICATION:
Per the terms of the Plan contract with the Michigan Department of Community Health, the following services do not require any type of prior authorization:
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- Emergency Room Services – Screening and Stabilization, Facility and Professional Components
- Family Planning Services at any provider
- STD Services at any provider
- Well-Women exams with a contracted provider
- Well-Child exams with a contracted provider
- Emergency Transportation
- Services provided by Federally Qualified Health Centers
- Services provided by Public Health Departments
Members may access any of the above services directly, without prior authorization from the PCP or PCHP.
BEHAVIORAL HEALTH SERVICES:
By our contract with the State of Michigan, ProCare Health Plan members are allowed 20 outpatient mental health visits per calendar year. Behavioral Health visits are referral services and are charged against the PCP referral fund. Members can access these services in several ways:
- PCHP has contracts with local behavioral health providers that will allow members to call them directly and schedule an appointment. The provider will then contact the Utilization Department for an approval number. A referral is faxed to the provider that includes the PCP information, which facilitates contact between the provider and PCP. Members can be directed to PCHP’s Customer Service for information. The number is 1-877-255-3055
- PCP’s may issue referrals for these services.
- Referrals are generated for the processing of payments only.
Inpatient behavioral health is not a benefit under the health plan. Members requiring inpatient psychiatric services must be referred by their county community mental health agency. ProCare Health Plan can assist members or providers in contacting agencies if necessary.
Substance abuse services are not a covered benefit of PCHP. Members seeking those services should be referred to the Community Mental Health board of their county of residence.
SKILLED NURSING:
Per contract with the State of Michigan, all ProCare Health Plan members have a limited skilled nursing benefit. This benefit covers inpatient admissions to physical rehabilitative facilities, not substance abuse rehabilitation facilities. Each request for admission is reviewed by the Medical Director or his / her designee for appropriateness of admission, length of stay, etc. Custodial care is not a covered benefit under Midwest Health Plan. Members needing admission for long-term non-rehabilitative care must be disenrolled to straight Medicaid. The Utilization Department will assist with this process.
INCENTIVES
PCHP does not give financial incentives for the denial of any type of service by the PCP or physician advisors. Financial incentives for decision makers do not encourage decisions that result in underutilization. Decisions are based solely on the appropriateness of care and service and existence of coverage.
UTILIZATION REVIEW PROVIDER
APPEAL PROCESS:
ProCare Health Plan recognizes that participating providers may choose to exercise their right to appeal a utilization management decision. A physician reviewer or other applicable reviewer is available to discuss any health UM denial decision during normal business hours. This may include a physician, pharmacist, or chiropractor.
The appeals process is established to facilitate this right to appeal as follows:
- If a provider disagrees with a Utilization Management decision, the provider has the right to appeal and must do so within 30 days of receipt of the decision. The provider must make the appeal in writing to the ProCare Health Plan Medical Director.
- If there is a specific reason that a provider is unable to supply the additional information within the time allotted (30 days), a 30-day extension will be granted upon written request. The request for extension MUST be postmarked no later than 30 days from the initial denial. The extension will be granted for an additional 30 days from the date of receipt.
- An appeal must include new supporting evidence and / or documentation. Portions of the medical record may be submitted, however, the submission of the medical record without an explanation will not be considered for appeal nor will it constitute a request for an appeal.
- Requests for an appeal of a Utilization Management decision received after 30 days or beyond the granted extension period will not be considered for an appeal.
- ProCare Health Plan will accept verbal appeals in emergent situations. These are defined as “health care issues requiring a response from the Medical Director or Associate Medical Director in less than 24 hours.”
- Upon the receipt of the appeal, the Medical Director or Associate Medical Director will review additional information supplied by the provider and gather other information as needed. The Medical Director or Associate Medical Director may solicit input from the physicians of the Peer Review Committee (or other groups of physicians designated for this purpose) prior to making a decision. No physician may participate in the decision process that could create a conflict of interest.
- The Medical Director or Associate Medical Director will give the provider an answer in writing within 30 days or less as medical necessity dictates.
- If the provider disagrees with the decision of the Medical Director or Associate Medical Director, the provider has the right to appeal the decision in writing to the Peer Review Subcommittee. This appeal must be received within 30 days of the denial of the appeal.
- The Peer Review Subcommittee will review all information, make a determination and inform the provider of its decision within 30 days after the its regular scheduled meeting.
- If the provider disagrees with the Peer Review Subcommittee’s decision, the provider has the right to appeal in writing to the Quality Improvement Committee. The appeal must be received within 30 days of the written denial from the Peer Review Subcommittee.
- The Quality Improvement Committee will review all information and inform the provider of its decision with 30 days of its regularly scheduled meeting. The decision of the Quality Improvement Committee is the final decision.
- All appeals are tracked and reported to the Quality Improvement Committee. At each level of appeal, the provider is informed in writing of the next step in the appeal process.
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