1)
All
Referrals to out-of-network providers (whether or not in network benefits are
requested) must be pre-authorized.
a)
The
referral should be received in writing.
b)
Out of
network referrals must be made by a network physician.
c)
Out of
network referral requests which are not by a network physician or which do not
contain adequate information will be handled in such a way as to encourage the
correction of the referral to be sufficient by:
i)
Returning
it to the sender with instructions
ii)
Corresponding with the sender to educate as to the requirements for this type of
referral.
2)
Out of
network services may be considered for reimbursement at the in-network benefit
level if:
a)
A specific
service is not available in the QualChoice network to which you have been
assigned.
i)
Note that
the availability of an equivalent service is adequate to establish that the
service is available in the network.
ii)
The lack of
availability of services in network is not generally established until an
appropriate in network resource has confirmed that the service is not available
in network.
iii)
Note that
there are limits on coverage for some services which apply whether the services
are sought in network or out of the network. The fact that a particular
non-covered service is not available in the network does not make a case for
coverage out of the network.
iv)
The absence
of a specific service in network is not proof the service requested exits
outside of the network. Competency in the requested service by the out of
network provider needs to be confirmed. Claims of superior competency is not a
basis for approval of In Network benefit coverage.
v)
The fact
that the member would prefer not to be seen by the available in-network
resource, or that the patient, having previously been seen by that physician has
developed such a dysfunctional relationship that the physician will no longer
consent to see the patient, does not negate the presence of a network resource,
and is not a reason to grant an out of network referral.
b)
Does the
member qualify for continuity of care consideration? (See the policy on
continuity of care)
3)
The
decision will result in one of the following:
a)
If
approved, the out of network services will be paid at the In Network benefit
level.
i)
. It is
important that the member and the receiving physician understand the extent of
services that are approved.
ii)
If it
becomes necessary for more services to be provided by the receiving physician,
the nature and extent of the additional services needs to be reported to us and
to the referring physician. Another referral request will be needed to ascertain
if additional services still meet the requirement for out of network referral.
b)
If the
services are or would be approved but QualChoice has a preferred out-of-network
provider, the services at a non-preferred out-of-network provider will not be
approved for In-Network benefits.
c)
If the
services requested are held not to be medically necessary, both the services and
the out of network referral will be denied and QualChoice will pay nothing
toward the services.