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
A written form from an in-network healthcare provider requesting authorization for
a specific scope of services to be provided by an out-of-network healthcare provider.
Health Tradition Health Plan must approve referrals to out-of-network healthcare
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 providers.
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 healthcare 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 healthcare services
received from out-of-network healthcare providers, a member must obtain a referral
from an in-network healthcare 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 healthcare 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 healthcare 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:
- Non-emergency ambulance services
- Durable medical equipment, disposable supplies, and prosthetics (for items costing
over $750)
- Experimental/investigational services
- Home healthcare
- Hospice care
- Non-emergency inpatient hospitalization
- Certain mental health and chemical dependency services
- Out-of-area services (except for emergency care and urgent care)
- Skilled nursing facility care
- 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 healthcare 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.
Outpatient Services
For individual and family counseling sessions, prior authorization is not required
for an evaluation and initial treatmen twhen 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 the following outpatient services:
- Psychological testing services
- Any outpatient service received at an out-of-network healthcare provider
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 healthcare provider, it is the member's responsibility to notify
Health Tradition Health Plan for continued covered services.