Referrals and prior authorization

This is the process of receiving written approval from Health Tradition Health Plan for certain services or products in advance of the service or product being provided. Health Tradition Health Plan must approve all referrals and prior authorization requests before covered services are provided to the member. Prior authorization does not guarantee payment of benefits.

• Referrals
• Prior authorization
• Emergency services
• Urgent care
• Inpatient services
• Mental health and chemical dependency services

Referrals

A written form from an in-network health care provider requesting authorization for a specific scope of services to be provided by an out-of-network health care provider is required. Health Tradition Health Plan must approve referrals to out-of-network health care providers before those services are received.

Below are some guidelines on referrals for each of the Health Tradition plans:

For all plans:

• Visits to in-network provider
  No referral is required

For Premier, Premier One, and 65Plus Plan Members:

• Visits to out-of-network providers
  Referral must be approved by Health Tradition Health Plan before the member receives the covered services requested by an in-network health care provider. Preventive services are not covered out-of-network.

For Premier Plus Plan Members only:

• Visits to out-of-network providers (and receive benefits at the in-network level).
  To receive coverage at the higher in-network benefit level for health care services received from out-of-network providers, a member must obtain a referral from an in-network provider. However, Health Tradition Health Plan must approve the referral before the covered services listed in the referral are eligible for payment at the in-network benefits level. Coverage at the in-network benefit level is limited to the type, frequency and duration of the health care services approved in the referral.
• Visits to out-of-network providers (and receive benefits at the out-of-network level).
  A member can receive covered services at the lower out-of-network benefit level from any out-of-network provider without a referral, including specialist services.

Prior authorization

Certain services, such as experimental treatments/drugs, certain procedures or some durable medical equipment require prior authorization. The Certificate of Coverage fully defines services requiring referrals or prior authorizations to obtain coverage.

Services requiring prior authorization include the following:

1.  Non-emergency ambulance services

2.  Durable medical equipment, disposable supplies, and prosthetics (for items costing over $750)

3.  Experimental/investigational services

4.  Home health care

5.  Hospice care

6.  Non-emergency inpatient hospitalization

7.  Certain mental health and chemical dependency services

8.  Out-of-area services (except for emergency care and urgent care)

9.  Skilled nursing facility care

10.  Transplants

Emergency services

Emergency care is medical treatment required unexpectedly and immediately because of an accidental injury or emergency illness.

A member may receive emergency care at any hospital without prior authorization. If the member is admitted to the hospital, the member must notify Health Tradition Health Plan within 48 hours, or as soon as medically possible, by calling the Utilization Management Department toll-free at 1-888-459-3020. Prior authorization is required for subsequent follow-up by an out-of-network health care provider. Emergency care is covered at any hospital for a full-time adult dependent/student outside the service area.

Urgent care

Urgent care situations are conditions that will worsen if you delay medical attention until the next available appointment, but are not life-threatening emergencies. A member may receive urgent care services without prior authorization.

Inpatient services

To receive coverage for non-emergency covered services from a hospital, the member must obtain prior authorization at least two days prior to an admission. For hospitalization following emergency care, the member should notify Health Tradition Health Plan within 48 hours, or as soon as possible, by calling the Utilization Management Department toll-free at 1-888-459-3020.

Mental health and chemical dependency services

Inpatient services

Covered services must be provided in a hospital or mental health or chemical dependency facility. To receive coverage for non-emergency covered services, the member must obtain prior authorization at least two days prior to an admission. For emergency care that requires hospitalization, the member must notify Health Tradition Health Plan within 48 hours, or as soon as medically possible. Members must call the Utilization Management Department toll-free at 1-888-459-3020.

Transitional treatment services

No prior authorization is required when services are provided by an in-network provider.

Mental health and chemical dependency services

Outpatient services

For individual and family counseling sessions, prior authorization is not required for an evaluation and initial treatment when the services are received by an in-network provider. If a member is utilizing an out-of-network healthcare provider, it is the member’s responsibility to notify Health Tradition Health Plan and obtain authorization.

Prior authorization is required for any outpatient service received at an out-of-network healthcare provider.

Prior authorization may be required for psychological testing services.  Please contact Health Tradition Health Plan for assistance.

Coverage outside of the service area for adult dependents/students – mental health/chemical dependency

A clinical assessment is required. If outpatient treatment services are recommended, coverage is provided for up to five outpatient visits. Health Tradition Health Plan will review the adult dependent’s/student’s condition following the five outpatient visits and will determine coverage of any additional services. If a member is utilizing an out-of-network health care provider, it is the member’s responsibility to notify Health Tradition Health Plan for continued covered services.