Treating providers are solely responsible for medical advice and treatment of members. The ABA Medical Necessity Guide does not constitute medical advice. The Applied Behavior Analysis (ABA) Medical Necessity Guide helps determine appropriate (medically necessary) levels and types of care for patients in need of evaluation and treatment for behavioral health conditions. In these situations, we will issue a "modified" response.īy clicking on “I Accept”, I acknowledge and accept that: As appropriate, we will substitute the "referred to" provider with a provider who is aligned to the capitation arrangement of the requesting provider. *Our referral system recognizes when a specialty capitation arrangement may apply. Learn more about our referral policy in the Office Manual for Health Care Professionals Submit patient referrals through one of our vendors Submit patient referrals through our provider portal Submit an electronic referral in one of two ways: In some instances, we will grant a "modified" response where C&T code 99499 replaces the rejected procedure code. We will return such requests and ask you to resubmit the code(s) using the precertification process. We do not accept procedure codes for services that require precertification. Authorized procedures are subject to the number of visits on the referral. Referrals submitted without a procedure code will default to a C&T referral (99499). We will pay specialists for performing associated covered services in an office setting, according to current claims processing guidelines. In most areas, consult and treat (C&T) referrals do not need to include the specialists’ procedures. C&T referrals – These are referrals submitted with CPT code 99499.We will only reimburse for the procedure code(s) that matches the code(s) on the referral. Primary care physicians (PCPs) should use these referrals when a member needs care for a specific health reason. Exact procedure code referrals – These are referrals submitted with code(s) other than 99499.Our guidelines for patient referrals allow us to authorize: Timely referrals can also help avoid claims reviews later. Keep costs down by referring your patients to specialists who are covered by their plan.
0 Comments
Leave a Reply. |
AuthorWrite something about yourself. No need to be fancy, just an overview. ArchivesCategories |