Pro Care requires that the PCP to obtain authorization to refer a Member to a participating specialist for office visits. The specialist must provide communication back to the PCP by fax, email, postal mail and/or telephone within two (2) weeks of the Member visit. This communication to the PCP promotes continuity of care as well as reduces the risk of duplicating services and/or treatments that could place the Member at risk. Failure to report back to the PCP violates billing reimbursement guidelines that could result in an audit and/or reimbursement recovery by Pro Care.

Referring a Member from the specialist office to another participating physician specialist must be done with the prior approval of the Member's PCP, when the services in question are of a non-emergent nature. Once this PCP approval has been obtained, the specialist is responsible for coordinating any supporting documentation for the referred to physician specialist and PCP. This documentation must be available at the time of the Member's visit to insure continuity of care, timely implementation of an appropriate treatment plan as well as reduces the risk of duplicating services and/or treatments that could place the Member at risk.

Any services referred to a non-participating specialist must have Pro Care's prior approval.

The specialist must note the name of the referring physician in Box 17 of the CMS 1500 submitted for the Member visit.

Specialists seeing a Member referred by a non-participating physician must have prior authorization from Pro Care for the office level visit, payment will be based on Medicaid Fee Schedule.