Standing Referrals. The Contractor will implement policies and procedures to allow for standing referrals to specialist physicians for Enrollees who have ongoing needs for care from such specialists, consistent with PHL Section 4403(6)(b).
Standing Referrals. Contractor shall provide for standing referrals to Specialists in accordance with Health and Safety Code Section 1374.16, as follows:
A. Contractor shall have in place a procedure for a Member to receive a standing referral to a Specialist if the primary care physician determines, in consultation with the Specialist and Contractor’s Medical Director or the Medical Director’s designee, that a Member needs continuing care from a Specialist. If a treatment plan is necessary in the course of care and is approved by Contractor, in consultation with the primary care physician, Specialist, and Member, a referral shall be made in accordance with the treatment plan. A treatment plan may be deemed unnecessary if Contractor approves a current standing referral to a Specialist. The treatment plan may limit the number of visits to the Specialist, limit the period of time that the visits are authorized, or require that the Specialist provide the primary care physician with regular reports on the health care provided to the Member.
B. Contractor shall have in place a procedure for a Member with a condition or disease that requires specialized medical care over a prolonged period of time and is life-threatening, degenerative, or disabling to receive a referral to a Specialist or specialty care center that has expertise in treating the condition or disease for the purpose of having the Specialist coordinate the Member’s health care. The referral shall be made if the primary care physician, in consultation with the Specialist or specialty care center and Contractor’s Medical Director or the Medical Director’s designee, determines that this specialized medical care is medically necessary for the Member. If a treatment plan is deemed necessary in the course of the care and is approved by Contractor, in consultation with the primary care physician, Specialist or specialty care center, and Member, a referral shall be made in accordance with the treatment plan. A treatment plan may be deemed unnecessary if Contractor approves the appropriate referral to a Specialist or specialty care center.
C. Determinations for standing referrals shall be made within three (3) business days from the date the request is made by the Member or the Member’s primary care physician and all appropriate medical records and other items of information necessary to make the determination are provided. Once a determination is made, the referral shall be made within four (4) business days of the date the p...
Standing Referrals. A Member’s PCP may issue a standing Referral when special conditions require ongoing care. A special condition is a condition or disease that is life-threatening, degenerative, or disabling and requires specialized medical care over a prolonged period of time. A standing Referral must be made in accordance to a treatment plan and Prior Approved in writing by our Medical Management team.
Standing Referrals. Consistent with utilization management, or unless otherwise set forth by statute, regulation or the Health Benefit Plan, Covered Individual shall be allowed to receive a standing referral, as defined in CRS 00-00-000 (64), for Medically Necessary treatment, to a specialist or specialized treatment center who is a Network/Participating Provider. The primary care physician for the Covered Individual, in consultation with the specialist and Covered Individual, shall determine that the Covered Individual needs ongoing care from the specialist in order to make the standing referral. A time period for the standing referral, not to exceed one (1) year unless authorized by Plan, shall be determined by the primary care physician in consultation with the specialist or specialized treatment center. The specialist or specialized treatment center shall refer the Covered Individual back to the primary care physician for primary care. Treatment provided by the specialist or specialized treatment center must comply with all provisions of the Covered Individual's Health Benefit Plan. The primary care physician shall record the reason, diagnosis or treatment plan necessitating the standing referral.
Standing Referrals. A Members may receive a standing referral for medically necessary treatment to a specialist or specialized treatment center participating in UBH's network. The primary care provider for the Members, in consultation with the specialist and Members, shall determine that the Members needs ongoing care from the specialist in order to make the standing referral. A time period for the standing referral of up to one year, or a longer period of time if authorized by UBH, shall be determined by the primary care provider in consultation with the specialist or specialized treatment center. The specialist or specialized treatment center shall refer the Members back to the primary care provider for primary care. To be reimbursed by UBH or Payor, treatment provided by the specialist shall be for a Members and must comply with provisions contained in the Member’s Benefit Plan. The primary care physician shall record the reason, diagnosis, or treatment plan necessitating the standing referral. UBH or an entity that contracts with UBH shall not penalize a primary physician who makes a standing referral of a Member to a specialist, nor shall the specialist treating the Member be penalized, with actions that include but are not limited to disincentives or disaffiliation, except for violations of Colorado Revised Statutes (“C.R.S.”) Section 10-1128.
Standing Referrals. Contractor shall provide for standing referrals to specialists in accordance with Health and Safety Code, Section 1374.16.
Standing Referrals. In accordance with Utah Code Xxx. § 31A-22-628 (2), a Member shall be allowed to obtain a standing referral to a specialist provider.
Standing Referrals condition is a condition or disease that is life - threatening, degenerative, or disab ling and requires specialized medical care over a prolonged period of time. A standing Referral must be made in accordance to a treatment plan and Prior Approved in writing by our Medical Management team.
