PCP referral and prior authorization policy and procedure

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Definitions

Primary care referral – A recommendation by which a primary care provider sends a member to another provider for services that are typically outside the PCP’s scope of practice.

Prior authorization – The prospective or concurrent review process used by Fallon Health to determine coverage of a particular medical service. Prior authorization involves the review of eligibility, level of benefits, servicing provider’s participating status and medical necessity. Depending on the contract, some groups for some product lines might be delegated for this process. If this is a question, contact your provider relations representative.

Referring provider – The provider initiating the referral

Servicing provider – The provider or facility providing the service

Services for which member may self-refer (within product):

  • OB/GYN visits 
  • Annual preventive gynecological visits
  • Medically necessary evaluations and treatment
  • Obstetrical visits
  • Mammogram
  • Oral surgery (impacted teeth only)
  • Routine eye exams
  • Outpatient mental health/substance use disorder

Services requiring prior authorization

The following services require prior authorization for HMO, ACO and POS members. Most high-tech imaging services require prior authorization through eviCore and Care Centrix.

  • All elective inpatient admissions
  • All services with out-of-product, tertiary, non-contracted and/or Peace of Mind Program™ providers or facilities
  • All unlisted CPT-4 and unspecified HCPCS codes
  • Specified DME and prosthetics and orthotics
  • Elective hospital/facility same-day surgery and ambulatory procedures on the procedure codes list
  • Genetic testing
  • Home health services
  • Infertility/assisted reproductive technology
  • Neuropsychological testing
  • Non-emergent ambulance
  • Office-based procedures identified on the procedure codes list
  • Oral surgery services and treatment
  • Oxygen
  • Plastic reconstructive surgery and treatment
  • Transplant evaluation

Prior authorization procedure

  • The requesting provider completes the Prior Authorization Request Form and faxes it to 1-508-368-9700.
  • Fallon will send a determination to the requesting provider, PCP and member.
  • PPO members are mustnotify Fallon of certain procedures, or a penalty may be applied

PCP referral process for HMO, POS and PPO members

Referrals for specialty care are required for commercial HMO and Fallon Senior Plan HMO members. POS members have the option of receiving care out-of-network without a referral. PPO members do not need a referral for specialty services.

  • The PCP refers the member to a specialist within the member’s product for medically necessary care. Contact the specialist by telephone, fax or mail, and provide the PCP’s name, NPI number, the reason for the referral and number of visits approved.
  • The specialist verifies member’s eligibility through the Fallon online eligibility tool, or POS device, or by contacting Fallon Customer Service at 1-800-868-5200, Monday, Tuesday, Thursday and Friday from 8:00 a.m. to 5:00 p.m.and Wednesday from 10 a.m. to 5 p.m.
  • The specialist treats the member according to the PCP’s request and exchanges clinical information with the member’s PCP.
  • The specialist submits a claim to Fallon with evidence of a referral (i.e., the PCP NPI number) from the member’s PCP. The following information should be entered on the CMS-1500 or electronic equivalent as evidence of the referral:
  • Box 17 – enter referring provider/PCP’s name
  • Box 17b – enter referring provider/PCP’s NPI number
  • Failure to include complete referral information (the referring provider’s name and NPI number) on the claims will result in a denial.
  • PCP referrals will be accepted retroactively up to 120 days from the date of the Remittance Advice Summary (RAS). Should an initial claim be rejected for lack of a referral number (i.e., the PCP NPI number), the specialist has 120 days from the date of the RAS to resubmit a corrected claim with the provider NPI number. Please note that all corrected claims must be dropped to paper and marked “corrected claim.” Corrected claims cannot be submitted electronically.
  • If a member does not have a valid referral, but visits a specialist for services that require a PCP referral, the specialist should contact the member’s PCP to obtain a PCP referral. If the PCP does not approve the referral, the specialist should inform the member of his or her financial liability and ask the member to sign a waiver of liability.
  • If a specialist decides that a member needs a service that he/she cannot provide, the specialist must consult with the member’s PCP, who will initiate a new referral to the appropriate specialist.
  • Please note that all services with out-of-product, tertiary, non-contracted and/or Peace of Mind Program™ providers or facilities require a preauthorization.

PCP referral and prior authorization process for ACO Medicaid members

A PCP referral for ACO members has an actual referral number given by the PCP.

To obtain a referral number the PCP can either call care services, fax in the standardized Request for Prior Authorization form to Fallon Health or enter the request via ProAuth.

PCP referrals will have a start date/end date with a specific number of visits approved. 

Specialists can confirm the PCP referral through the PCP, through ProAuth or the Authorization Lookup tool or by calling the Fallon Health Care Services department.

ACO-specific rules for Berkshire Fallon Health Collaborative

  • PCP referrals are not required for specialty care services with  a BFHC Core provider.
  • PCP referrals are required for BFHC Affiliate providers.
  • Fallon will allow 7 days for a retroactive entry of a PCP referral.
  • Out-of-Network services, including specialty visits, require prior authorization.  For all office and facility-based services identified in the Provider Manual as requiring authorization, the PCP or specialist must obtain prior Plan authorization, and the facility must provide notification to the Plan.
    For more information, see the Berkshire Fallon Health Collaborative fact sheet.

ACO-specific rules for Fallon 365 Care

  • PCP referrals are not required for specialty care within the Fallon 365 Care primary network, which consists of Reliant Medical Group including Southboro Medical Group.
  • PCP referrals are required for Fallon 365 Care Affiliate providers.
  • Fallon will allow 7 days for a retroactive entry of a PCP referral.
  • Out-of-network services, including specialty visits, require prior authorization. For all office and facility-based services identified in the Provider Manual as requiring authorization, the PCP or specialist must obtain prior Plan authorization, and the facility must provide notification to the Plan.
    For more information, see the Fallon 365 Care fact sheet.

ACO-specific rules for Wellforce Care Plan

  • PCP referrals are required for all specialist visits in the Wellforce Care Plan network
  • PCP referrals are required for all Wellforce Care Plan Affiliate providers..
  • Fallon will allow 30 days for a retroactive entry of a PCP referral.
  • Out- of-network services, including specialty visits, require prior authorization.  For all office and facility-based services identified in the Provider Manual, the PCP or specialist must obtain prior Plan authorization, and the facility must provide notification to Wellforce Care Plan. 
  • Wellforce Care Plan members do not need a PCP referral to an in-network specialist for the following services:
  • Ob/GYN and maternity 
  • Family planning at any in-network or MassHealth-contracted provider
  • Routine eye exams 
  • Outpatient behavioral health
    For more information, see the Wellforce Care Plan fact sheet.