Medical Policy

Effective Date:01/01/1995 Title:Out of Network Referrals
Revision Date:05/01/2018 Document:BI109:00
CPT Code(s):None
Public Statement

Effective Date:

a)    This policy will apply to all services performed on or after the above Revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1)    All requests for in network benefits for non-emergency services at an out of network provider require pre-authorization by QualChoice.

2)    QualChoice reserves the right to designate a specific out of network provider at which the approved services must be obtained to receive In Network benefits.

3)    Some of our plans allow members the right to self-referral and to access out-of-network providers; under such plans the member may access any out-of-network provider he or she wishes, at the reduced Out of Network benefit level. Members should refer to their coverage documents to fully understand this benefit and the potential financial impact. QualChoice is unable to protect members from balance billing by out of network providers.

4)    In all plans, non-emergency services rendered by out of network providers will be covered at the Out of Network benefit level unless such  services have been pre-approved by QualChoice before they are rendered. The member will receive written notification from QualChoice of that approval and what specific services are included for In Network benefit coverage. All services not specifically approved will be covered at the Out of Network benefit level. If you do not have written notification, then the referral has NOT been approved.  If approved, QualChoice will negotiate an agreed upon price with the out of network provider designated.  

5)    Approval will be granted only for services which are not reasonably available within the QualChoice network to which you are assigned. “Reasonably available” is defined as the availability of an equivalent service or a service provided by a qualified provider.  Requests must indicate a specific deficiency in the QualChoice network to which you are assigned.  Absence of a service within the QualChoice network is not proof that service is available 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.  Requests for out of network referrals to receive In Network benefits must be provided to QualChoice by a QualChoice participating provider Requests from members will be returned with the response that the request must come from a QualChoice participating provider. Such requests should be in writing, submitted by mail or fax.

6)    The standard turn-around time for out of network referrals is five working days. It may take longer if additional clinical information must be obtained, or if responses from providers are not received promptly. If the member requires a faster response, either the member or the referring provider may request expedited consideration.

7)    Expedited consideration is granted based on the urgency of medical need, not convenience. We will do everything we can to turn around an expedited request as fast as possible – the response will be within 3 working days.

Medical Statement

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.

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Effective 01/01/2018: Clarification language added regarding documentation of specific in network deficiency and confirmation of specific competency out of network.

Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.

Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.