Section 2 5 - Specialist Guidelines - Health Plan

1 Specialist Guidelines | Section 2 Specialist Guidelines 1. You will be listed on The Health Plan provider directory under specialists THAT MAY REQUIRE REFERRALS. Although The Health Plan has eliminated the call-in referral to The Health Plan Medical Department, the PCP is still the coordinator of all medical care for the member, and still needs to coordinate referrals to specialists . Members who are a part of the ASO line of business may still require phone in referrals to Specialist . 2. If you wish to change to a different category on the provider directory, you must make a request in writing to Provider Relations. Your request will be reviewed in accordance with The Health Plan's credentialing Guidelines to assure you meet any qualifications required for a specific category.

2 3. Except in cases of emergency treatment, specialists shall only treat members upon referral from a PCP or a SCP. 4. Except in cases requiring emergency treatment, specialists must submit a report to the appropriate PCP or SCP concerning the proposed plan of specialty treatment, including possible hospitalization or surgery, as soon as possible after examination of a member. 5. specialists should contact the PCP to arrange referrals to another physician. Specialist -to- Specialist referrals are not generally permitted. In emergency situations, a Specialist to whom a patient has been referred may refer that patient to another Specialist only in cases where the referral is related to care pertaining to his/her specialty, , specialized surgery and/or care requiring tertiary services.

3 The plan recommends; however, that the Specialist communicate with the PCP regarding the need for the referral in such instances. This may be done, after the fact, in instances where the emergency may require immediate action. 6. specialists will send a copy of the member's treatment record to the appropriate PCP or SCP.