8 Health Care Management Services
8.2 Referral Guidelines
PCPs may only refer members to IntegraNet contracted network specialists to ensure the specialist receives appropriate clinical background data and is aware of the member’s ongoing primary care relationship. If a member does not have out-of-network benefits, such as an HMO member and has expressed a desire to receive care from a different specialist or you believe the required specialty is not available within the contracted network, contact Provider Services at 833-908-0105. Provider must obtain precertification from IntegraNet before referring members to nonplan providers. Referring a Medicare member out-of-network will result in the claim denying with member liability unless urgent, emergent, out of area renal dialysis or if prior authorization was obtained from the plan.
Providing Noncovered Serivces Advanced Notification
For services that require prior authorization or are non-covered by the plan (i.e., statutory exclusion), it becomes extremely important that IntegraNet authorization procedures are followed. If a member elects to receive such care the member cannot be held financially responsible unless notified in advance of the noncovered services. In such cases when the network physician fails to follow IntegraNet authorization protocols, IntegraNet may decline to pay the claim in which case the physicians will be held financially responsible for services received by the member. Again, CMS prohibits holding the member financially responsible in these cases.
CMS-issued guidance concerning Advance Notices of Noncoverage. The ABN is an FFS document and cannot be used for Medicare Advantage denials or notifications. Per CMS, the ABN is given to beneficiaries enrolled in the Medicare Fee-For-Service (FFS) program. It is not used for items or services provided under the Medicare Advantage (MA) Program or for prescription drugs provided under the Medicare Prescription Drug Program (Part D). CMS advised Medicare Advantage plans that contracted providers are required to provide a coverage determination for services that are not covered by the member’s Medicare Advantage plan. This will ensure that the member will receive a denial of payment and accompanying appeal rights. If there is any doubt about whether a service is not covered, please seek a coverage determination from the health plan.