Referrals or Prior Notifications
A referral or prior notification is a request by a PCP or a participating specialist for a member to be evaluated and/or treated by a participating specialty physician and/or facility. SHP uses two types of forms and processes:
1. Quick Authorization Form (QAF)
For those services included on the SHP Quick Authorization Form (QAF) (see the Forms Section of this handbook) a referral is NOT required. Primary Care Physicians (PCP’s) can refer a member to a articipating specialist and to many frequently requested services and procedures at free-standing facilities with the Simply Healthcare Plans Quick Authorization Form (QAF) without contacting the health plan for prior authorization.
IMPORTANT NOTE: Communication with the Plan prior to the provision of care is not necessary when using the QAF; however, all inpatient services, outpatient hospital services (including diagnostics), and ASC services do require an authorization (see section below).
Prenatal care referrals are NOT to be made using the QAF.
**The QAF form is not valid for any inpatient or outpatient hospital services or for any consultations or procedures not listed on the form, or for out-of-network providers.
The PCP or specialist ordering the consultation or test is required to fax or mail a copy of the completed QAF to the participating provider or facility that will be providing the service(s), or to give a copy to the member so that it is presented at the time of the service.
Services that Do NOT Require Prior Authorization or QAF:
* Family Planning*
* Participating Office/free standing laboratory tests at labs consistent with CLIA guidelines
* Emergent transportation services
* Urgent or emergent care at participating Urgent Care centers or any Emergency Room
* County Health Departments (CHD), Federally Qualified Health Centers , Rural Health Clinics and federally funded migrant health centers when providing:
* Vaccines
* STD diagnosis/treatment
* Rabies diagnosis/immunization
* Family planning services and related pharmaceuticals
* School health services and urgent services
*NOTE: If the member receives Family Planning Services from a non-network Medicaid provider, the Plan will reimburse the provider at the Medicaid reimbursement rate, unless another payment rate is negotiated.
List of procedure - Authorization required
All of the following procedures and services require Prior Plan Notification and must be provided in a SHP participating facility*:
o Inpatient and Observation Admissions, as noted above
o Admission to any rehabilitation and skilled nursing facility
o All surgical procedures, inpatient or outpatient
o The following have special reporting requirements (refer to Forms Section):
* Abortions
* Hysterectomies
* Sterilization procedures
o Cosmetic or Reconstructive Surgery, including but not limited to:
* Breast reconstruction or reduction
* Blepharoplasty
* Venous procedures
* Sclerotherapy
o Services and items:
* Allergy (immunotherapy), exept for those services identified on the QAF
* Ambulance transportation (non emergent)
* Amniocentesis
* Cardiac and pulmonary rehabilitation programs
* Circumcisions after 12 weeks of age
* Court-ordered services
* Chemotherapy
* Dialysis
* DME, including apnea monitors and bili-blankets
* Upper endoscopies at colonoscopies at hospitals
* Genetic testing
* Gamma Knife, Cyberknife
* Hearing aids
* Home Health Services
* Hospice care
* Hyperbaric Oxygen Therapy (HBO)
* Investigational and experimental procedures and treatments
* IV Infusions
* Laboratory services in POS 22 and 24
* Lithotripsy
* Mental Health (See Mental Health Section)
* Nutritional counseling
* MRI’s, MRA’s
* Oral Surgery
* Oxygen therapy and equipment
* Out-of-Network Services
* Pain Management and or Pain Injections
* PET Scans
* Prenatal care
* Orthotics and Prosthetics, including Cranial Orthotics
* Physical, Occupational and Speech Therapy
* Radiation therapy
* SPECT scans
* Transplants and pre and post transplant evaluations
* Wound Care and wound vacuums
* Drugs that require pre-authorization
* Any services or procedures not listed on the Quick Authorization Form (QAF)
*Unless the service is only available in a non-participating facility.
Understand Prior Authorization - Full details
Prior Authorizations:
Prior authorization (pre-service requests) allows for the use of quality, cost-efficient covered health care services and helps to ensure that effective transition of care planning is done so that members receive the most appropriate level of care within the most appropriate setting. Prior authorization must be obtained for all services not included on the Quick Authorization Form (QAF) for PCP’s (see section above) that require an authorization.
SHP’s UM Department evaluates requests for services/procedures and makes determinations based on medical necessity, covered benefits and appropriateness based on SHP’s approved utilization criteria (Interqual) and evidence-based, nationally recognized clinical guidelines. Only a Medical Director may issue an adverse determination, with the exception of denials due to benefit issues.
No provider or any other individual or SHP employee or associate is rewarded for issuing denials of coverage or care. Financial incentives will NOT encourage decisions that would result in underutilization nor are incentives to create barriers to care and services.
Prior Authorization Requests are to be made through the SHP’s UM Pre-Certification Department.
Prior Authorization or Notification Process:
* Providers are to fax the Referral & Authorization Form (refer to Forms Section) to the SHP’s Utilization Management Pre-Certification Department at Fax number 1-800-283- 2114 or by calling the PreCertification Telephone Queue 1-800- 887-6888, ext 2271.
* Routine (NOT STAT/URGENT) requests are processed within fourteen (14) calendar days of the Plan receiving the authorization request and having received all supporting clinical information.
STAT/URGENT requests are processed within seventy-two (72) hours of the Plan receiving the request and having received the supporting clinical information.
NOTE: STAT/URGENT Authorizations should be CALLED IN to the SHP Pre-Certification Authorization Telephone Queue and NOT faxed, and the caller should identify the request as “STAT/URGENT”. These requests should always meet the defined medical criteria for such which are:
STAT/URGENT: Any condition where failure to issue an immediate response may result in an IRREVERSIBLE SIGNIFICANT, ADVERSE outcome of health and/or function.
* Each Referral & Authorization Form received from the provider’s offices will be date and time- stamped, manually or electronically and is reviewed for completeness, eligibility, benefits, PCP and specialist network affiliation
* The Referral & Authorization Form must be accompanied by supporting clinical information for medical necessity determination
* An authorization number will be provided, via fax, to the PCP, specialist and other provider(s) that will provide services to the member, when the request is completed and approved
* All authorization requests and documentation of supporting clinical information will be entered and maintained within the SHP computer system for future reference and claims payment
When faxing a Prior Authorization Request, the SHP Referral & Authorizations Form must be completed. The requesting provider is reminded to include:
* Member demographic information (i.e. name, sex, DOB, SHP Member Number)
* Provider demographic information
* Requesting provider (i.e. name, SHP Provider Number, phone number, fax number, contact person)
* Referred-to specialist/facility (i.e. name, SHP Provider Number, address, phone number, fax number, date of service, and identification if PAR (Plan participating provider/facility) or Non-PAR (not a Plan participating provider/facility)
* Diagnoses for authorization request, including ICD-9 Code(s)
* Procedure(s) for authorization request, including CPT/HCPCS Code(s)
* Number of visits requested, frequency and duration
* Pertinent medical history and treatment, laboratory and/or radiological data, physical examinations/referrals that support the medical necessity for the requested service(s).
Requests that do not meet medical necessity, based upon approved criteria are reviewed by the Medical Director for a final determination. The Medical Director may conduct a peer-to-peer discussion with the requesting provider, if indicated.
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