Specialty Care. The MCO must provide or arrange for necessary specialty care, including women’s health services. The MCO must allow women direct access to a women’s health specialist (e.g., gynecologist, certified nurse midwife) within the network for women’s routine and preventive health care services, in addition to direct access to a primary care physician for routine services, if the primary care provider is not a women’s health specialist. The MCO should have a policy encouraging provider consideration of beneficiary input in the provider’s proposed treatment plan.
Specialty Care. Contractor shall establish a comprehensive network to ensure the availability and accessibility of specialists and subspecialists to meet the needs of Enrollees. Care Coordinators shall have authority to authorize services and will not require approval by Contractor’s medical director for the majority of services in accordance with recognized Medically Necessary criteria. For Enrollees with special healthcare needs who require an ongoing course of treatment or regular care monitoring, Contractor must provide mechanism for Enrollee to directly access specialists, as appropriate for the condition and needs.
Specialty Care. The MCO must provide or arrange for necessary specialty care, including behavioral health services, SUD services, women’s health services, and CSED services (if applicable). In accordance with 42 CFR §438.206(b)(2), the MCO must allow women direct access to a women’s health specialist (e.g., gynecologist, certified nurse midwife) within the network for women’s routine and preventive health care services, in addition to direct access to a PCP for routine services, if the PCP is not a women’s health specialist. The MCO must have a policy encouraging provider consideration of beneficiary input in the provider’s proposed treatment plan.
Specialty Care. Health Care services provided by a physician or other Health Care provider who has received advanced clinical training and may have a postgraduate academic degree (includes, but is not limited to, medical consultants, surgeons, optometrists, and physical and respiratory therapists).
Specialty Care. For high volume specialty care, routine appointments must be available within 30 calendar days of referral. High volume specialists include cardiologists, neurologists, hematologists/oncologists, OB/GYNs, and orthopedic physicians. For other specialty care, consultation must be available within one month of referral or as clinically indicated.
Specialty Care a. LCJ shall ensure that inmates whose serious medical or mental health needs extend beyond the services available at LCJ shall receive timely referral for specialty care to appropriate medical or mental health care professionals qualified to meet their needs.
b. LCJ shall ensure that inmates who have been referred for outside specialty care by the medical staff or another specialty care provider are scheduled for timely outside care appointments and transported to their appointments. Inmates awaiting outside care shall be seen by Qualified Medical Staff as medically necessary, at intervals of no more than 30 days, to evaluate the current urgency of the problem and respond as medically appropriate.
c. LCJ shall maintain a current log of all inmates who have been referred for outside specialty care, including the date of the referral, the date the appointment was scheduled, the date the appointment occurred, the reason for any missed or delayed appointments, and information on follow-up care, including the dates of any future appointments.
d. LCJ shall ensure that pregnant inmates are provided adequate pre-natal care. LCJ shall develop and implement appropriate written policies and protocols for the treatment of pregnant inmates, including appropriate screening, treatment, and management of high risk pregnancies.
Specialty Care. The contractor shall have a procedure by which a new enrollee upon enrollment, or an enrollee upon diagnosis, who requires very complex, highly specialized health care services over a prolonged period of time, or with (i) a life-threatening condition or disease or (ii) a degenerative and/or disabling condition or disease, either of which requires specialized medical care over a prolonged period of time, may receive a referral to a specialist or a specialty care center with expertise in treating the life-threatening disease or specialized condition, who shall be responsible for and capable of providing and coordinating the enrollee's primary and specialty care. If the contractor or primary care provider in consultation with the contractor's medical director and a specialist, if any, determines that the enrollee's care would most appropriately be coordinated by such specialist/specialty care center, the contractor shall refer the enrollee. Such referral shall be pursuant to a care plan approved by the contractor, in consultation with the primary care provider if appropriate, the specialist, care manager, and the enrollee (or, where applicable, authorized person). The contractor-participating specialist/specialty care center acting as both primary and specialty care provider shall be permitted to treat the enrollee without a referral from the enrollee's primary care provider and may authorize such referrals, procedures, tests and other medical services as the enrollee's primary care provider would otherwise be permitted to provide or authorize, subject to the terms of the care plan. If the specialist/specialty care center will not be providing primary care, then the contractor's rules for referrals apply. Consideration for policies and procedures should be given for a standing referral when on-going, long-term specialty care is required. If the contractor refers an enrollee to a non contractor- participating provider, services provided pursuant to the approved care plan shall be provided at no additional cost to the enrollee. In no event shall the contractor be required to permit an enrollee to elect to have a non contractor- participating specialist/specialty care center. For purposes of this Article a specialty care center shall mean the Centers of Excellence identified in Section B.4.10 of the Appendices. These centers have special expertise in treating life-threatening diseases/conditions and degenerative /disabling diseases/conditions.
Specialty Care. When all treatment options by the Contractor’s Primary Care Provider are exhausted, and/or the Participant’s condition requires treatment by a Specialty Care Provider, Contractor shall refer the Participant to the Department in accordance with the Department's referral guidelines. Contractor shall assure that all appropriate examinations and Ancillary Services are completed prior to the referral, and that the justification for the referral is noted in the Participant’s medical record and included in the referral to the Department. If the Contractor uses non-physician providers, the referral shall be reviewed and approved by a physician prior to being submitted. Contractor shall utilize eConsult to initiate specialty referrals, provided that it has been implemented for the particular specialty at the time of the referral. Contractor shall not be responsible for non-obligated radiological tests, as defined in Section II.3 above, recommended by the eConsult Specialty Care Provider. If eConsult is unavailable for any reason, Contractor shall submit referrals through the Department's Referral Processing System (RPS). Contractor shall coordinate any and all follow-up care with the Participant once the Participant is repatriated to his or her Medical Home.
Specialty Care. ICTs and embedded Care Coordinators will be available to assist Medical Home Providers in referring Enrollees for specialty care.
Specialty Care. PHS Medical shall provide Specialty Care Services in accordance with Department policies and procedures at Institutions designated by and on a schedule approved by the Department. On-Island Specialty Care Services to be provided by PHS Medical shall include: Cardiology; Dermatology; Ears, Nose, Throat.; Nephrology; Neurology; Optometry; Orthopedics; Oral Surgery; Physical Therapy; Podiatry; Surgery; Hand Surgery; Ob/GYN; at the hours of service specified in Attachment 4 attached hereto and incorporated by reference. This list is subject to change upon request from the Department subject to Part I Article IV.A.1 of this Agreement. PHS Medical shall immediately notify the Department if at any time it is not able to provide Specialty Care Services as otherwise scheduled by the Department. At the discretion of the Department, PHS Medical may hire a certified specialist in wound care to provide care in the NIC and other designated facilities, as deemed necessary.
