Referrals


Primary Care Provider (PCP) Responsibilities

The Primary Care Provider (PCP) is the cornerstone of NextLevel Health’s services delivery model. The PCP serves as the “medical home” for the member. The “medical home” concept assists in establishing a member- provider relationship, supports continuity of care, eliminates redundant services, and ultimately improves outcomes in a more cost-effective way.

PCPs provide screening, well care, and referrals to community health departments and other agencies in accordance with HFS (Department of Healthcare and Family Services) provider requirements and public health initiatives.

Specialist Responsibilities

The PCP is responsible for coordinating the Member’s healthcare services and making referrals to specialty providers when care is needed that is beyond the scope of the PCP. The specialty physician may order diagnostic tests without PCP involvement by following NextLevel Health referral guidelines. The specialty physician must abide by the prior authorization requirements when ordering diagnostic tests; however, the specialist may not refer to other specialists or admit to the hospital without the notification to the PCP, except in a true emergency situation.

The specialist must:
1
Obtain referral or authorization from the Member’s PCP and/or NextLevel Health Medical Management department (Medical Management) as needed before providing services
2
Coordinate the Member’s care with the PCP
3
Provide the PCP with consult reports and other appropriate records within five business days

Transition of Care /Continuity of Care Referral Process

For Integrated Care Program and the Family Health Plan Program, a Non-Affiliated Provider can continue to treat the NLH Enrollee for an initial 90-day transition period or through the postpartum period. To do so, the Non-Affiliated Provider must agree to accept reimbursement from the Health Plan at the Health Plan’s established rates, follow the Health Plan’s Quality Assurance requirements, and agree to follow the Health Plan’s policies and procedures, this which includes the Health Plan’s referral and authorization requirements.

Instructions for a Specialist to Obtain Referrals

The specialist can obtain referrals directly for the customer to another specialist with the following limits:

1
The PCP referred the Member to the specialist
2
The following five (5) conditions must be met:

  • Diagnosis must be related to the specialty and/or service to be obtained
  • Diagnosis must be related to reason PCP referred to referring specialist
  • Treatment must be a covered benefit of the health plan
  • Member must be currently under the care of the referring specialist
  • Referral must be made to a participating provider

3
The specialist provides follow-up documentation to the PCP for all referrals obtained for further specialty care.
4
Referrals for the following specialty care are excluded from this process and must be referred back to the PCP to obtain referral: Non-participating providers, Chiropractor, Dermatology, Otolaryngology, Maxillofacial Surgeon, Podiatry, Optometry, Transplant Specialist, and Reconstructive (Plastic) Surgeon with the exception of breast reconstruction.
5
The referral must be obtained prior to the services being rendered
6
Emergency Services do not require a referral