Common use of Standing Referrals Clause in Contracts

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 proposed treatment plan, if any, is submitted to Contractor’s Medical Director or the Medical Director’s designee. D. Standing referrals do not require Contractor to refer to a Specialist who, or to a specialty care center that, is not employed by or under contract with Contractor to provide health care services to Members, unless there is no Specialist within the Provider Network that is appropriate to provide treatment to Members, as determined by a primary care physician in consultation with Contractor’s Medical Director as documented in the treatment plan.

Standing Referrals. Contractor shall provide for standing referrals to Specialists 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 specialist if the primary care physician determines, in consultation with the Specialist specialist and Contractor’s Medical Director or the Medical Director’s designee, that a Member needs continuing care from a Specialistspecialist. If a treatment plan is necessary in the course of care and is approved by Contractor, in consultation with the primary care physician, Specialistspecialist, 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 Specialistspecialist. The treatment plan may limit the number of visits to the Specialistspecialist, limit the period of time that the visits are authorized, or require that the Specialist 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 specialist or specialty care center that has expertise in treating the condition or disease for the purpose of having the Specialist specialist coordinate the Member’s health care. The referral shall be made if the primary care physician, in consultation with the Specialist 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 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 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 proposed treatment plan, if any, is submitted to Contractor’s Medical Director or the Medical Director’s designee. D. Standing referrals do not require Contractor to refer to a Specialist specialist who, or to a specialty care center that, is not employed by or under contract with Contractor to provide health care services to Members, unless there is no Specialist specialist within the Provider Network plan network that is appropriate to provide treatment to Members, as determined by a primary care physician in consultation with ContractorXxxxxxxxxx’s Medical Director as documented in the treatment plan.

Standing Referrals. Contractor shall provide arrange for standing referrals to Specialists 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 physicianPrimary 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 proposed treatment plan, if any, is submitted to Contractor’s Medical Director or the Medical Director’s designee. D. Standing referrals do not require Contractor to refer to a Specialist who, or to a specialty care center that, is not employed by or under contract with Contractor to provide health care services to Members, unless there is no Specialist within the Provider Network that is appropriate to provide treatment to Members, as determined by a primary care physician in consultation with Contractor’s Medical Director as documented in the treatment plan.

Standing Referrals. Contractor shall provide for standing referrals to Specialists 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 proposed treatment plan, if any, is submitted to Contractor’s Medical Director or the Medical Director’s designee. D. Standing referrals do not require Contractor to refer to a Specialist who, or to a specialty care center that, is not employed by or under contract with Contractor to provide health care services to Members, unless there is no Specialist within the Provider Network that is appropriate to provide treatment to Members, as determined by a primary care physician in consultation with Contractor’s Medical Director as documented in the treatment plan.

Standing Referrals. Contractor shall provide for standing referrals to Specialists 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 specialist if the primary care physician determines, in consultation with the Specialist specialist and Contractor’s Medical Director or the Medical Director’s designee, that a Member needs continuing care from a Specialistspecialist. If a treatment plan is necessary in the course of care and is approved by Contractor, in consultation with the primary care physician, Specialistspecialist, 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 Specialistspecialist. The treatment plan may limit the number of visits to the Specialistspecialist, limit the period of time that the visits are authorized, or require that the Specialist 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 specialist or specialty care center that has expertise in treating the condition or disease for the purpose of having the Specialist specialist coordinate the Member’s health care. The referral shall be made if the primary care physician, in consultation with the Specialist 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 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 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 proposed treatment plan, if any, is submitted to Contractor’s Medical Director or the Medical Director’s designee. D. Standing referrals do not require Contractor to refer to a Specialist specialist who, or to a specialty care center that, is not employed by or under contract with Contractor to provide health care services to Members, unless there is no Specialist specialist within the Provider Network plan network that is appropriate to provide treatment to Members, as determined by a primary care physician in consultation with Contractor’s Medical Director as documented in the treatment plan.

Standing Referrals. Contractor shall provide for standing referrals to Specialists 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 specialist if the primary care physician determines, in consultation with the Specialist specialist and Contractor’s Medical Director or the Medical Director’s designee, that a Member needs continuing care from a Specialistspecialist. If a treatment plan is necessary in the course of care and is approved by Contractor, in consultation with the primary care physician, Specialistspecialist, 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 Specialistspecialist. The treatment plan may limit the number of visits to the Specialistspecialist, limit the period of time that the visits are authorized, or require that the Specialist specialist provide the primary care physician with regular reports on the health care provided to the Member.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 specialist or specialty care center that has expertise in treating the condition or disease for the purpose of having the Specialist specialist coordinate the Member’s health care. The referral shall be made if the primary care physician, in consultation with the Specialist 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 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 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 proposed treatment plan, if any, is submitted to Contractor’s Medical Director or the Medical Director’s designee. D. Standing referrals do not require Contractor to refer to a Specialist specialist who, or to a specialty care center that, is not employed by or under contract with Contractor to provide health care services to Members, unless there is no Specialist specialist within the Provider Network plan network that is appropriate to provide treatment to Members, as determined by a primary care physician in consultation with ContractorXxxxxxxxxx’s Medical Director as documented in the treatment plan.

Standing Referrals. Contractor shall provide for standing referrals to Specialists 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 Specialists if the primary care physician determines, in consultation with the Specialist Specialists 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 proposed treatment plan, if any, is submitted to Contractor’s Medical Director or the Medical Director’s designee.designee.‌ D. Standing referrals do not require Contractor to refer to a Specialist who, or to a specialty care center that, is not employed by or under contract with Contractor to provide health care services to Members, unless there is no Specialist within the Provider Network that is appropriate to provide treatment to Members, as determined by a primary care physician in consultation with Contractor’s Medical Director as documented in the treatment plan.

Standing Referrals. Contractor shall provide for standing referrals to Specialists 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 specialist if the primary care physician determines, in consultation with the Specialist specialist and Contractor’s Medical Director or the Medical Director’s designee, that a Member needs continuing care from a Specialistspecialist. If a treatment plan is necessary in the course of care and is approved by Contractor, in consultation with the primary care physician, Specialistspecialist, 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 Specialistspecialist. The treatment plan may limit the number of visits to the Specialistspecialist, limit the period of time that the visits are authorized, or require that the Specialist 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 specialist or specialty care center that has expertise in treating the condition or disease for the purpose of having the Specialist specialist coordinate the Member’s health care. The referral shall be made if the primary care physician, in consultation with the Specialist 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 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 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 proposed treatment plan, if any, is submitted to Contractor’s Medical Director or the Medical Director’s designee. D. Standing referrals do not require Contractor to refer to a Specialist specialist who, or to a specialty care center that, is not employed by or under contract with Contractor to provide health care services to Members, unless there is no Specialist specialist within the Provider Network plan network that is appropriate to provide treatment to Members, as determined by a primary care physician in consultation with ContractorXxxxxxxxxx’s Medical Director as documented in the treatment plan.