Urgent and Emergency Care
Managed care laws in Wisconsin include a uniform standard of coverage for emergency
room care. Emergency care is hospital or medical treatment which is required unexpectedly
and immediately because of an accidental injury or emergency illness. An emergency
shall exist when a member's symptoms are of sufficient severity to lead a prudent
layperson to reasonably conclude that immediate medical attention is necessary.
It does not include elective medical treatment for an illness or injury for which
the need for care could reasonably have been foreseen. Health Tradition
may not deny coverage for emergency services that a reasonably prudent layperson
would consider an emergency.
Health Tradition’s emergency care provisions are outlined below:
- Prior authorization is not required for emergency care at any hospital
- Follow-up services must be provided in the appropriate setting to be eligible for
coverage and may require prior authorization
- Emergency medical services or urgent care that is provided to a covered dependent
who is a full-time student attending school outside the geographic service area
of the plan will be covered by Health Tradition
- Questions about emergency care can be directed to the Utilization Management department
at 608-781-9692 (local) or 1-888-459-3020 (toll-free)
Prior Authorization
Prior Authorization is the process of receiving written approval from the Plan for
certain services or products in advance of the service or product being provided.
Prior authorization does not guarantee payment of benefits.
Prior Authorization is required for the following services:
- Certain diet drugs
- Certain durable medical equipment items under $750
- All durable medical equipment over $750
- Cosmetic services/procedures
- Elective inpatient admission
- Experimental/investigational services/procedures
- Gastric bypass
- Home healthcare services
- Hospice care
- Outpatient mental health/chemical dependency services (excluding 65Plus)
- Skilled nursing facility admission
- Transplants
To obtain assistance with prior authorization, contact Health Tradition at 608-781-9692
(local) or toll-free 1-888-459-3020 or fax at 608-781-9654.
Prior authorization requirements are subject to change upon notification.
Referrals
A written referral form is required when a practitioner refers a member to an out-of-network
healthcare provider. A referral is a written form from an in-network healthcare
provider authorizing a specific scope of services to be provided by an out-of-network
healthcare provider. The Plan must approve referrals to out-of-network healthcare
providers before those services are received. A referral is not required when a
practitioner refers a member to an in-network specialist. A list of in-network specialists
is available to members in their Health
Tradition provider directory.
If a member requires services from a specialist not available in-network, Mayo Clinic
in Rochester, MN is the preferred out-of-network referral center. A written referral
must be approved by the Plan prior to services being rendered. The member's in-network
healthcare provider coordinates referrals. This is obtained by completing an external
referral form. Click here for referral and authorization
forms.
To obtain assistance with prior authorization or referral requirements, contact
Health Tradition at 608-781-9692 or toll-free 1-888-459-3020.
Mental Health/Chemical Dependency
Members enrolled in a Health Tradition plan may seek mental health or chemical dependency
services without obtaining a referral from their primary care provider. It is the responsibility
of the in-network mental health/chemical dependency provider to contact Health Tradition at 608-781-9692 (local) or toll-free 1-888-459-3020 to authorize services when necessary.
Prior authorization requirements for mental health/chemical dependency services
include:
- Elective admissions
- Urgent/emergent inpatient admissions (notify the Plan within 48 hours)
- Psychological testing
Prior Authorization for Psychological Testing
Prior authorization is required for any psychological testing. If services are provided
without obtaining prior approval from Health Tradition, services will be denied.
The Prior
Authorization Request for Psychological Testing form
must be completed before services have been provided.
To request additional authorization forms, contact Health Tradition Health Plan at 608-781-9692.
Completed authorization forms can be faxed to Health Tradition Mental Health Services at
608-781-9654 or mailed to:
Health Tradition
Mental Health Services
P.O. Box 188
La Crosse, WI 54602-0188
To obtain assistance with prior authorization or referral requirements, contact
Health Tradition at 608-781-9692 (local) or toll-free 1-888-459-3020.
Chiropractic Management
Health Tradition has an agreement with Health Services Management, Inc. (HSM) to
manage our chiropractic network. Management services provided by HSM include:
- Provider selection assistance
- Provider credentialing
- Provider contracting
- Claims payment administration
- Utilization management
- Quality management
Please contact Health Tradition Customer Service toll-free 1-877-832-1823 to verify
chiropractors participating in the network.
For information on chiropractic plan procedures, please refer to your HSM provider
administrative manual. If you do not have a manual available, please contact HSM
at toll-free 1-800-432-3640.
Medical Guidelines
Health Tradition utilizes InterQual®, a nationally recognized utilization management
criteria. These criteria are used in determinations for:
- Type of treatment
- Frequency of treatment
- Diagnostic testing
- Preventive healthcare services
Upon request, Health Tradition will share these criteria. Contact the Utilization
Management Department at 608-781-9692 (local) or toll-free 1-888-459-3020.