a strong foundation for growth and diversification

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referral process improvement
fchp is here
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what is changing?

• The FCHP requirement for the PCP to submit a
  referral to FCHP prior to or in time with the
  date of service
• is being replaced with
• The requirement for the PCP to provide the
  specialist their FCHP vendor ID number and for
  the specialist to submit that number on the claim

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why do this?

• to simplify the pcp referral process for
  providers and members

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timeline

• September 1, 2006 FCHP is piloting the new
  process with select provider groups.
• During the pilot, please note that when receiving
  referrals or requesting referrals from providers
  who are not part of your group, the existing FCHP
  PCP referral process will still be in place.
• January 1, 2007 GO LIVE!

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definitions
Primary care referral A recommendation by which
a primary care provider sends a member to another
contracted provider for services that are
typically outside the PCPs scope of
practice. Preauthorization The prospective or
concurrent review process used by Fallon
Community Health Plan to determine coverage of a
particular medical service. Preauthorization
involves the review of eligibility, level of
benefits and medical necessity. Referring
provider The provider initiating the referral
Servicing provider The provider or facility
providing the service

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member self-referral (within product) stays the
same

• ob/gyn visits
• Annual preventive gynecological visit
• Medically necessary evaluations and treatment
• Obstetrical visits
• mammogram
• oral surgery (impacted teeth only)
• routine eye exams
• outpatient mental health/substance abuse

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preauthorization procedure does not change

• All services currently requiring preauthorization
  will continue to require preauthorization.
• 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 identified on the procedure
  codes list
• genetic testing
• home health services
• infertility/assisted reproductive technology
• neuropsychological testing
• nonemergent ambulance service
• office-based procedures identified on the
  procedure codes list
• oral surgery services and treatment
• oxygen
• PET scans
• plastic reconstructive surgery and treatment
• transplant evaluation

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preauthorization procedure

• The requesting provider submits a request via the
  Online Referral Tool or completes the required
  sections of the new request for authorization
  form. Beginning in January 2007, the form will be
  available on the FCHP website.
• FCHP will send a determination to the requesting
  provider, PCP and member. The status will also be
  available via the Online Referral Tool.
• To contact the Care Services Department with
  questions related to preauthorization, call
  1-866-ASK-FCHP, press 3.

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pcp referral procedure

• Referrals for specialty care are required for
  commercial HMO and Fallon Senior Plan HMO
  members.
• The PCP refers the member to a specialist within
  the members product for medically necessary
  care.
• PCP contacts the specialist by telephone, fax or
  mail, and provides the PCPs name, the FCHP
  provider number (vendor number), the reason for
  the referral and number of visits approved.
• There is no longer a 12 month/12 visit maximum
• The specialist verifies members eligibility
  through the FCHP online eligibility tool, POS
  device or by contacting FCHP Customer Service at
  1-866-ASK-FCHP, press 1, Monday through Friday
  from 830 a.m. to 500 p.m.
• The specialist treats the member according to the
  PCPs request and exchanges clinical information
  with the members PCP.

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pcp referral procedure

• The specialist submits a claim to FCHP with
  evidence of a referral (the PCPs FCHP vendor
  number) from the members PCP. The following
  information should be entered on the CMS-1500 or
  electronic equivalent as evidence
• Box 17 enter referring provider/PCPs name
• Box 17a enter referring provider/PCPs FCHP
  vendor number
• For FCHP direct claims submitters
• Loop 2310A Segment NM1 enter the referring
  provider/PCPs name
• Loop 2310A Segment REF with the G2 qualifier
  enter referring provider/PCPs FCHP vendor number
• FCHPs contracted claims clearinghouses have the
  capability to send the referring provider's FCHP
  vendor number.
• Failure to include complete referral information
  (the referring providers name and vendor number)
  on the claims will result in a denial.

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pcp referral procedure (cont.)

• PCP referrals will be accepted retroactively up
  to 120 days from the date of service. Should an
  initial claim be rejected for lack of a referral
  number (the PCP vendor number), the specialist
  has 120 days from the date of the RAS to resubmit
  a corrected claim with the provider vendor
  number. Please note that all corrected claims
  must be dropped to paper and marked corrected
  claim.
• If there is no vendor number on the claim,
  providers may call 1-866-ASK-FCHP, press 1 and
  FCHP will accept the vendor number via the
  telephone within the 120 day period. A corrected
  claim will not be mandatory.
• If a member does not have a valid referral but
  visits a specialist for services that require a
  PCP referral, the specialist should inform the
  member of his or her financial liability and ask
  the member to sign a waiver of liability. If the
  specialist contacts the members PCP to obtain a
  PCP referral and the PCP does not approve the
  referral, the member would be liable.

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pcp referral procedure (cont.)

• If a specialist decides that a member needs a
  service that he/she can not provide, the
  specialist must consult with the members PCP who
  will initiate a new referral to the appropriate
  specialist.
• Please remember that all services with
  out-of-product, tertiary, non-contracted and/or
  Peace of Mind Program providers or facilities
  require a preauthorization from FCHP.

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online referral tool

• The FCHP online referral tool will continue to be
  accessible for requests for preauthorization.
• outpatient/same day surgery
• inpatient
• DME
• transportation
• The primary care referral screens will no longer
  be accessible after April 1, 2007.

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chiropractic referral procedure

• Beginning on January 1, 2007
• For a referral to a participating chiropractor,
  the PCP must provide the member and/or the
  chiropractor with a written prescription.
• The chiropractor needs to submit a copy of the
  prescription to American Specialty Health when
  submitting the initial claim.

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provider relations
Provider Relations is always available for
questions, concerns and compliments!
1-866-ASK-FCHP, press 4 or
askfchp_at_askfchp.org
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• questions?

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• thank you!