Allways Health Partners (Commercial)
Referral shall mean a verbal or written authorization provided by a Member’s Primary Care Provider (PCP) or other Participating Provider to a Consultant or other Provider for the furnishing of Covered Services. A Referral must specify the nature and extent of services to be rendered to a Member, and must comply with all applicable requirements as set forth in the Provider Manual. This definition includes all forms of the word referral. Notwithstanding the foregoing, NEQCA Participating Providers shall not be subject to AHPs’ standard referral requirements with respect to referrals made to NEQCA Participating Providers for Members who have a NEQCA Primary Care Provider.
BCBSMA (Commercial) HMO
Referrals to PO Providers: PO Primary Care Providers shall not be subject to the Plans’ standard referral requirements with respect to referrals made to PO Providers for Members who have a PO Primary Care Provider (the "Referral Simplification Arrangement").
4.15.1. For referrals subject to the Referral Simplification Arrangement, the PO and all PO Providers must obtain and maintain all records and other documentation required for referrals under the Agreement, comply with the referral policies and criteria, as modified from time to time, as required by the Agreement and in effect for the Plan and the HMO Blue Product at the time of the referral, and be subject to the Plans’ oversight protocols.
4.15.2. The PO agrees to permit any of the Plans authorized representatives, at any time reasonably convenient to both the Plans and the PO, or as applicable, the PO Provider, to conduct referral management audits, or such other audits of this referral arrangement as may be necessary to satisfy the requirements of the Plans, federal and state regulatory bodies, Accounts and accrediting bodies. The Plans will make reasonable efforts to provide prior written notice of the request for referral management audits to the PO. To the extent allowed by applicable law, regulation or contractual obligations, the Plans shall notify the PO of relevant audit findings so that the PO may further educate, as needed, any PO Provider.
4.15.3. The PO agrees that the Plans have the right to revoke this Referral Simplification Arrangement upon ninety (90) days prior written notice if the Plans determine that the PO or PO Providers have not administered or managed referrals satisfactorily and/or if requisite reporting and disclosure requirements are not otherwise fully met in a timely manner unless the PO rectifies such actions within thirty (30) days. Additionally, the Plans may terminate this Referral Simplification Arrangement without cause upon one hundred and eighty (180) days prior written notice.
Harvard Pilgrim Healthcare (Commercial) HMO
Referral Simplification is in place. No contractual language exists. Per Yvette Trotman at HPHC: If the PCP has an established referral circle with Harvard Pilgrim (usually among specialists in the PCP’s care unit), a referral transaction is not required. However, if a Massachusetts PCP is referring an HMO or POS product member outside of their referral affiliation, a referral transaction is necessary.
Tufts Health Plan (Commercial) (in place except for PPO and USFHP)
Tufts HP has eliminated the requirements for referrals for all in-Provider Organization referrals related to HMO and POS Products. This exclusion from the referral requirement does not include PPO Products or USFHP. Additionally, Tufts Health Plan Programs requiring Tufts Health Plan's internal authorization such as the Mental Health Program and targeted diagnosis Programs are also not included in this exclusion from referrals
Wellforce Care Plan
As announced on 4/15/21 in WCP Network Update, Fallon and WCP leadership made a decision to lift the in-network PCP referral requirement permanently, not just during the public health emergency. PCP referrals to in-network specialists are no longer required. Out of network care, and certain high cost services, continue to require prior authorization.
The referral simplification covers the office visit to the specialist. If a procedure is done in the office that requires any type of authorization, this would not be covered.
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