Referrals and Authorizations

• General Information
• Referral
  • Voice Activated Referral
  • Paper Referrals
  • Out-of-Plan Referrals
  • Referrals for 2nd Surgical Opinions
  • Specialty Care Practitioners
  • Renal Dialysis Services
  • Audiology and Speech Therapy
  • Self-Referral
• Authorizations
  • Guidelines/Criteria
  • Review of Authorized Services
  • Chiropractic Services
  • Durable Medical Equipment
  • Skilled Nursing Facility
  • Physical/Occupational/Speech Therapy
  • Rehabilitation
  • Home Health Care
  • Home Infusion
  • Hospice Services
  • Pharmacy Services
• New Technology

Referrals and Authorizations are necessary in order to preserve the primary care practitioner’s Gatekeeper relationship with the patient. Both processes allow Gateway to manage the care of its member population. The major differences between referrals and authorizations are highlighted below:

• Referrals allow the primary care practitioner to approve specialty services for members on their panel.
• Authorizations allow Gateway to confirm eligibility of the member prior to receiving services; to assess the medical necessity and appropriateness of care; to establish the appropriate site for care; and to identify those members who would benefit from care management.

In certain instances, members do not require a referral from the primary care practitioner to see a participating specialty care practitioner. For the following services, members can self-refer:

• OB/GYN Services
• Family Planning Services (Family Planning services do not have to be rendered by a participating provider)
• Dental services
• Routine vision
• Chiropractic services (an authorization must be obtained by the chiropractic office, including the initial evaluation)
• Mental health/substance abuse services

Some services, such as hospital admissions, require authorization by the Gateway Utilization Management Department. To authorize a service, please call Gateway’s Utilization Management Department at 1-800-392-1146.

To determine which services require a referral or authorization, please refer to Gateway’s Quick Reference Guide for Referrals and Authorizations in the Forms and Reference Materials Section of this Manual.

When a primary care practitioner determines that a member requires medical services or treatment outside of the primary care practitioner’s office, the primary care practitioner must issue a referral to a participating facility or specialty care practitioner. If services are performed in a hospital setting, the referral should be issued to the hospital’s provider identification number. Primary care practitioners may not issue referrals to other primary care practitioners.

Gateway’s Digital Voice Assistant (DIVA) may be used by primary care practitioners and OB/GYNs to issue a referral, and by specialty care practitioner and hospitals to verify and review a referral. To use the system, call 1-800-642-3515, and please follow the prompts, or use the guide below for a quick reference.

TO ENTER A REFERRAL TO A SPECIALIST OR HOSPITAL

To Issue a Referral , you will need:

• Provider ID Number ("Practice Number")
• Member ID Number
• Specialist/Hospital Provider ID Number ("Practice Number") for the referred provider
• Type of referral, and number of visits

The system will provide a referral number and provides an option to fax a confirmation of the referral information to the specialist/hospital.

After dialing into DIVA at 1-800-642-3515, Press 1 to retrieve information regarding Pennsylvania members, then Press 2 to enter a new referral. Follow the prompts below.

Provider Identification Number?
Enter your group provider number

Member Identification Number?
Enter the member's 8 digit ID number (as it appears on the member's ID card)

Specialist/Hospital Provider Identification Number?
Enter the group provider number of the specialist/hospital to which you wish to refer the member. Finish by pressing the # key

(pause)  Verification of Identification Numbers

Type of Referral
Press 1 To enter a general referral for three visits within the next 90 days

Press 2 To enter a referral for allergy or pain management services for nine visits within the next 90 days

Press 3 To enter a referral for dialysis, chemotherapy or radiation therapy for 90 visits within the next 90 days
Please enter the beginning date for the referral. Referrals can be back-dated seven calendar days. Enter the two digit month, the two digit day, and the four digit year. Press 1 if the repeated date is correct. Press 2 if the repeated date is incorrect. Press the * key to begin again

Save Referral?
Press 1 To save the referral (wait for referral ID number)
Press 2 To discard the referral


Additional Instructions:
Press 1 To repeat the referral number
Press 2 To enter a new referral for the same PCP
Press 3 To enter a new referral for a different PCP
Press 4 To fax a referral (see options below)
Press 5 To return to the main menu
Press 6 If you are finished
Press 9 To hear this menu again
Press 0 To be connected to a Provider Servicing Representative

If you chose 4:
To fax a referral, choose one of the following options:
PLEASE NOTE: The number of the practitioner will be reviewed via the automated system if one is found; Please assure that this is the number that you wish to send the fax to. See additional options below for choosing the default fax or entering a new fax number.
Press 1 To send a fax to the PCP only
Press 2 To send a fax to the specialist/hospital only
Press 3 To send a fax to both the PCP and the specialist/hospital
Press 4 To return to the main menu without sending a fax
Press 9 To hear this menu again
Press # To return to the previous menu

If you chose 1, 2 or 3:
To send a fax, choose one of the following options:
Press 1 To use the fax number stored in the database
Press 2 To enter a fax number (allows you to enter any fax number)
Press # To return to the previous menu

TO VERIFY OR REVIEW A REFERRAL
If a referral is found that matches the information entered, the system will provide the following information:

• Provider ID Number
• Member ID Number
• Referral Case Number
• Effective Date and Expiration Date
• Number of Visits Approved

Provider Number?
Enter your group provider identification number

Member ID Number?
Enter the member's 8-digit Gateway ID number (as it appears on the member's ID card)

(pause) Referral Information
If there is a match, the following information will be provided:
PCP ID Number
Referral Case Number
Expiration Date
Member ID Number
Effective date
Number of Visits Approved
Specialist/Hospital ID Number

Playback Options:
Press 1 To play the referral information again
Press 2 To check for subsequent referrals
Press 3 To check for a referral using the same PCP
Press 4 To check for a referral using a different PCP or specialist
Press 5 To fax a list of reviewed referrals (see options below)
Press 6 To return to the main menu
Press 7 To exit
Press 9 To hear this menu again
Press 0 To speak with a Provider Servicing Representative

If you chose 5:
To fax a referral, choose one of the following options:
PLEASE NOTE: The number of the practitioner will be reviewed via the automated system if one is found; Please assure that this is the number that you wish to send the fax to. See additional options below for choosing the default fax or entering a new fax number. Press 1 To send a fax to the PCP only
Press 2 To send a fax to the specialist/hospital only
Press 3 To send a fax to both the PCP and the specialist/hospital
Press 4 To return to the main menu WITHOUT sending the fax
Press 9 To hear this menu again
Press # To return to the previous menu

If you chose 1, 2 or 3:
To send a fax, choose one of the following options:
Press 1 To use the fax number stored in the database
Press 2 To enter a fax number (allows you to enter any fax number)
Press # To return to the previous menu

Note: DIVA is only for referrals from PCPs to specialists and hospitals and for referrals from OB/GYNs to hospitals. Authorization is still required for certain services.  Specialists and hospitals may only review referrals.

**You may press "0" followed by the "#" sign at any time to speak to a Provider Servicing Representative.

Gateway strongly encourages practices to utilize the DIVA System outlined above; however, if you utilize a paper referral form, the procedure used to complete and submit a referral is as follows:

1. Check your practice’s Member List or call Gateway’s Eligibility Verification Line to verify the member’s eligibility.
2. Assure that the needed service does not require an authorization from Gateway.
3. Select a participating specialist or facility appropriate for the member’s medical needs from Gateway’s Provider On-line Directory. If an appropriate provider is not listed in the Directory, please call Provider Services for assistance.

Once a participating provider is selected from Gateway’s On-Line Directory, the primary care practitioner’s office completes the following sections of the Referral Form:

1. Primary Care Information:
   • Complete the primary care practitioner Name, Practice Address, and Telephone Number.
   • Fill in the Practice’s 7-digit Gateway Provider ID Number.
2. Patient Information
   • Complete the Patient’s Name.
   • Fill in the Member’s 8-digit Gateway Member ID Number.
   • Complete the diagnosis and/or complaint field being as specific as possible. The diagnosis can be an ICD-9 (preferred) code or a written description.
   • Complete the Patient’s Designated Lab if lab testing is being conducted.
3. Specialty Provider or Facility Information
   • SPECIALTY CARE PROVIDER: Complete the Specialist group name and Gateway Provider ID Number for services rendered at office site only.
   • FACILITY PROVIDER: Complete the Facility name and Gateway Facility ID Number for services rendered at outpatient facility to allow both facility and practitioner services to be covered.
4. Referral Services
   If you are referring a member for services that DO NOT REQUIRE authorization, you can check the appropriate service and specify additional information as requested on the form.
5. PCP Signature
   The paper referral form must be signed by the member’s primary care practitioner. If an office staff member completes the referral, the staff member must place their initials after the practitioner’s stamp or signature. AN UNSIGNED PAPER REFERRAL FORM IS NOT VALID.
6. Referral Date
   The Referral Form must be dated. If the Referral Form is not dated, Gateway will date according to receipt date at the claim office. Payment for referral and authorized services is contingent upon the patient being an enrolled Gateway member at the time of the service.
7. Referral Copies
   Copy 1 Primary Care Practitioner Return to Gateway
   Copy 2 Specialist Return to Gateway
   Copy 3 Primary Care Practitioner/Specialist/Hospital Record

Occasionally, a member may need to see a specialty care practitioner outside of Gateway’s provider network. When the need for out-of-plan services arises, the primary care practitioner must contact Gateway’s Utilization Management Department to obtain an authorization. The Utilization Management Department will review the request and make arrangements for the member to receive the necessary medical services with a specialty care practitioner in collaboration with the recommendations of the primary care practitioner. Every effort will be made to locate a specialty care practitioner within an accessible distance to the member.

Second surgical opinions may be requested by Gateway, the member, or the primary care practitioner. When requesting a second surgical opinion consultation, Gateway recommends that you issue a referral to a consulting practitioner who is in a practice other than that of the attending practitioner, or the practitioner who rendered the first opinion and possesses a different tax identification number than the attending practitioner.

When a Gateway member schedules an appointment with a specialist, the office should remind the member that a referral from the primary care practitioner is needed in order to receive treatment from the specialist, with the exception of a self-referred benefit. Specialty care practitioners should verify the existence of a valid referral through the DIVA System by calling 1-800-642-3515 prior to providing treatment.

If a paper referral form is utilized, the specialty care practitioner must review the referral form to verify that the form is valid. A valid form is signed by the primary care practitioner and has a referral date within the last ninety (90) days.

If other services are needed in addition to those authorized by the primary care practitioner, a treatment plan must be completed and forwarded to the primary care practitioner for authorization. The primary care practitioner can then issue additional referrals based upon the recommendations of the specialty care practitioner.

Since specialists cannot refer members to other specialists, the primary care practitioner must refer the member to another specialist. If a specialist recommends that the patient should be seen by another specialty care practitioner, the specialist must contact the primary care practitioner, and the primary care practitioner may then examine the patient and/or review the consult report prior to referring the patient to another specialist. The only exception to this is for neonatologists who may issue a referral to other participating hospitals and/or specialists for babies discharged from the NICU who require service before seeing their primary care practitioner. Referrals should be issued under the baby’s Gateway ID Number. If the baby does not have an ID Number, the practitioner should call Gateway’s Utilization Management Department for authorization.

In unusual situations, the specialist or primary care practitioner may contact Gateway’s Utilization Management Department at 1-800-392-1146.

Please contact Gateway’s Utilization Management Department if a member requires renal dialysis services. By calling Gateway a determination of eligibility for services can be determined. Although authorization for these services is not required, a referral from the primary care practitioner is needed. If home dialysis services are necessary, an authorization from Gateway’s Utilization Management Department is needed.

Gateway members under the age of 21 are eligible to receive audiological services including hearing aids and ear molds. The member’s primary care practitioner must issue a referral for audiological services to a participating, licensed practitioner, licensed audiologist or an outpatient hospital clinic. Prior to dispensing aids and/or ear molds, the audiological practitioner must obtain authorization through the ordering practitioner from Gateway’s Utilization Management Department. Reimbursement rates for hearing aids, ear molds, repair parts and any specialty items not covered on the Medical Assistance Fee Schedule should be negotiated at the time of authorization, prior to rendering services.

Members may refer themselves for the following types of care:

Dental
When a member joins Gateway, the member may self-refer to any participating United Concordia Companies, Inc. dentist directly without a referral from the primary care practitioner. Should specialty dental care be needed, the dentist can refer the member to a dental specialist.

Certain oral surgery procedures, such as removal of partial or total bony impacted wisdom teeth, and procedures which involve cutting of the jaw, are covered by Gateway through Gateway’s panel of oral surgery providers. Members requiring these services must be referred by their primary care practitioner to a Gateway participating oral surgeon. The primary care dentist may need to provide x-rays or other information to the primary care practitioner to facilitate the referral. The oral surgeon is responsible for authorizing surgical procedures with Gateway prior to rendering the service (procedures provided in the oral surgeons office are not subject to the authorization process). When a dental procedure requires the use of a Special Procedures Unit (SPU), the dental provider must contact United Concordia Companies, Inc. for authorization.

Emergency
Members are informed through the Member Handbook how and when to utilize emergency services.

Eye Examinations
Gateway members may self-refer to any Davis Vision participating provider for a routine eye exam. Corrective lenses and frames may be obtained through any participating optician, optometrist or ophthalmologist. There is no need for the primary care practitioner to issue a referral. Should the member require additional medical services, rendered by a participating ophthalmologist or optometrist, the member will require a referral from the primary care practitioner.

Mental Health/Substance Abuse
Members are permitted to self-refer for mental health and substance abuse services. Please refer to the Quick Reference Section of this manual for the telephone numbers for members to call.

OB/GYN Services
Female Gateway members may self-refer to any participating OB/GYN for any condition, not just for an annual exam or suspected pregnancy. When a member self-refers to the OB/GYN’s office, the OB/GYN’s office is required to contact Gateway to verify eligibility of the member.

The function of an authorization is to confirm the eligibility of the member, verify coverage of services, assess the medical necessity and appropriateness of care, establish the appropriate site for care, and identify those members who would benefit from care management or disease management. Gateway’s Utilization Management Department assesses the medical appropriateness of services using McKesson’s Interqual Procedure Criteria and the Department of Public Welfare/HealthChoices definition of medical necessity when authorizing the delivery of healthcare services to plan members. The definition of medical necessity is: A service or benefit is Medically Necessary if it is compensable under the MA Program and if it meets any one of the following standards:

• The service or benefit will, or is reasonably expected to, prevent the onset of an illness, condition or disability.
• The service or benefit will, or is reasonably expected to, reduce or ameliorate the physical, mental or developmental effects of an illness, condition, injury or disability.
• The service or benefit will assist the Member to achieve or maintain maximum functional capacity in performing daily activities, taking into account both the functional capacity of the Member and those functional capacities that are appropriate for Members of the same age.

Determination of Medical Necessity for covered care and services, whether made on a Prior Authorization, Concurrent Review, Retrospective Review, or exception basis, must be documented in writing.

The determination is based on medical information provided by the Member, the Member’s family/caretaker and the Primary Care Practitioner, as well as any other Providers, programs, agencies that have evaluated the Member.

All such determinations must be made by qualified and trained Healthcare Providers. A Healthcare Provider who makes such determinations of Medical Necessity is not considered to be providing a healthcare service under this Agreement.

The Utilization Management Department is committed to assuring prompt, efficient delivery of healthcare services and to monitor quality of care provided to Gateway members. The Utilization Management Department can be contacted at 1-800-392-1146 between the hours of 8:30 AM and 4:30 PM, Monday through Friday. The following options can be used to reach Gateway’s Utilization Management Department for specific information:

When calling before or after operating hours or on holidays, practitioners are asked to leave a voicemail message and a Utilization Management Representative will return the call the next business day. Urgent requests, pharmacy requests, and home health requests requiring a visit when the Gateway Utilization Management Department is closed, or urgent/emergency inpatient place of service admission called in after hours are directed to call 1-800-392-1147. A Gateway Medical Director is available for review of these requests when necessary. For urgent or emergency situations, Gateway requires that the practitioner notify the plan within forty-eight (48) hours or two (2) business days of rendering the service.

The following services require an authorization from Gateway:

• All Hospital Admissions
• Outpatient Surgical Procedures
• Speech, Occupational or Physical Therapies (Members can be referred to any Gateway participating hospital for speech, occupational or physical therapy sessions)
• Referrals for specialty care requiring greater than three visits, unless otherwise noted
• MRI/MRAs (authorization obtained by calling NIA)
• CT Scans/Bone Densitometry/Nuclear Cardiology (authorization obtained by calling NIA)
• Short Procedure Unit Services
• Procedures performed in labs that require anesthesia
• All services to be provided by an out-of-plan practitioner/provider (including durable medical equipment and home health)
• Durable Medical Equipment items $500.00 or greater or not covered on the MA Fee Schedule regardless of cost
• All Durable Medical Equipment rentals $500.00 or greater monthly
• Home Healthcare
• All Non-covered Services
• Hospice
• Home Infusion
• Hearing Aides and Ear Molds
• Skilled Nursing Facility Admissions
• Rehabilitation Hospital Admissions
• Chiropractic Services
• Podiatric Services

The following information is needed to authorize a service. Please have this information available before placing a call to the Utilization Management Department:

1. Member Name
2. Member’s 8-digit Gateway ID Number
3. Diagnosis (ICD-9 Code or precise terminology)
4. Procedure Code (CPT-4, HCPCS, or MA Coding) or billing codes for durable medical equipment requests
5. Treatment Plan
6. Date of Service
7. Name of Admitting/Treating Practitioner
8. Name of the Practitioner/Provider requesting the authorized treatment
9. Provider of Service 7-digit Gateway ID Number
10. History of the current illness and treatments
11. Any other pertinent clinical information

Authorization is the responsibility of the admitting practitioner or ordering provider and can be obtained by calling Gateway’s Utilization Management Department at 1-800-392-1146. If a service requires authorization and is being requested by a participating specialist, the specialist’s office must call Gateway to authorize the service. Hospitals may verify authorization by calling the Gateway Utilization Management Department. Physical, occupational or speech therapy requires authorization by the ordering practitioner or the primary care practitioner.

When a call is received, the above information will be reviewed, and the member’s eligibility verified. However, since a member’s eligibility may change prior to the anticipated date of service, eligibility must be verified on the date of service.

Medical Necessity Criteria are established guidelines to be applied by non-physician, licensed professionals to authorize services as medically necessary and at the appropriate level of care.

If an authorized service is not able to be approved as proposed by the practitioner, alternate programs such as home healthcare, rehabilitation or additional outpatient services will be suggested to the practitioner by the UM staff. If an agreement cannot be reached between the practitioner and the Utilization Management staff the case will be referred to Gateway’s Medical Director for review. A practitioner may appeal the decision within ninety (90) days of the date of the denial notice. Please refer to the Practitioner Complaints and Grievances Section of this manual for the process to appeal a decision.

The definition of Medical Necessity is as follows: A service or benefit is medically necessary if it is compensable under the Medical Assistance Program and if it meets any of the following standards:

1. The service or benefit will, or is reasonably expected to, prevent onset of an illness, condition, or disability.
2. The service or benefit will, or is reasonably expected to, reduce or ameliorate the physical, mental or developmental effects of an illness, condition, injury or disability.
3. The service or benefit will assist the member to achieve or maintain maximum functional capacity in performing daily activities, taking into account both the functional capacity of the individual and those functional capacities that are appropriate for individuals of the same age.

The determination is based on medical information provided by the member, the member’s family/caretaker and the primary care practitioner, as well as any other practitioner/providers, programs, agencies that have evaluated the member. All such determination must be made by qualified and trained practitioners/providers.

Any participating practitioner may request authorization for chiropractic services by calling Gateway’s Utilization Management Department at 1-800-392-1146 Option #3. All visits, including the initial visit, require authorization by Gateway and must be medically necessary. Member eligibility must be verified prior to rendering services by calling the Member Eligibility Verification Line at 1-800-642-3515. Members may self-refer for chiropractic services; however, the chiropractic office must call Gateway for authorization including the initial evaluation.

The only therapy Gateway will authorize is a simple manipulation for an acute spinal problem. Other requests will be referred to the Physician Advisor for review and determination. Additionally, one chiropractic evaluation will be authorized per course of treatment. Requests for children under the age of 16 are referred to Gateway’s physician advisor for approval. Only one visit per day can be authorized.

Participating chiropractors may not render radiological services in the office. X-rays may only be done at a Gateway participating facility, and no authorization will be given for these services to be done in a chiropractic office setting. Members requiring radiological services (including CT or MRI) or other diagnostic testing should be referred back to their primary care practitioner.

Gateway members are eligible to receive any covered and medically necessary durable medical equipment needed for home healthcare. When ordering durable medical equipment, these procedures must be followed:

• If the cost of a single item or multiple quantities of a single item is $500.00 or greater as reimbursed by Medical Assistance, the ordering practitioner/provider must obtain authorization from the Utilization Management Department. A referral from the primary care practitioner is not required, but a written prescription and Gateway authorization are necessary to obtain the item.
• Rental equipment must be authorized if the monthly rental cost is $500.00 or greater.
• Covered items under $500.00 can be obtained from a participating durable medical equipment provider with a prescription from the ordering practitioner/provider. A referral from the primary care practitioner and Gateway authorization is not required. Provider Services or Utilization Management can direct practitioners to a contracted vendor to supply durable medical equipment. Durable Medical Equipment vendors are also listed in the Gateway Specialty Care Practitioner Directory. A written prescription is required to obtain the item.
• Any item not covered by Medical Assistance, regardless of price, requires authorization by the Utilization Management Department.
• Regardless of price, when a miscellaneous code is requested, an authorization from Gateway’s UM Department is required.
• Due to frequent interruptions of Pennsylvania Medical Assistance coverage, Gateway strongly recommends that all providers verify eligibility if the need for an item or service extends beyond the calendar month in which the authorization was given.
• All medical supplies including wound care, ostomy, enteral products, diapers, and incontinence products must be obtained through a contracted durable medical equipment vendor as opposed to a participating pharmacy.
• Oral enterals must be obtained through a participating durable medical equipment provider. Based on the cost of the product ordered, an authorization from Gateway’s Utilization Management Department may be necessary if the product is $500.00 or greater. Please do not direct members to retail pharmacies such as Giant Eagle, Rite Aid, etc. for these services.
• When ordering durable medical equipment practitioners can contact a participating durable medical equipment provider to receive the appropriate billing code(s) before calling Gateway’s Utilization Management Department or practitioners can call and request Gateway’s staff work directly with a participating durable medical equipment provider to obtain the appropriate billing code and cost. Please call Gateway’s Provider Services Department at 1-800-392-1145 if you need an updated list of participating providers.
• Durable medical equipment provided by non-participating providers requires an authorization from the Gateway Utilization Management Department.
• Incontinence items will be covered by Gateway without requesting an Explanation of Benefits from any other plan; however, if the billed charge is $500.00 or greater, and/or a miscellaneous code is used to request the supply, a Utilization Management authorization will be required according to plan guidelines. Any services provided by non-participating providers always require an authorization.

The following information will provide assistance to offices when ordering durable medical equipment services:

1. Patient Name, Gateway ID Number, Prior Authorization Number (If Applicable)
2. Durable Medical Equipment Vendor/Provider Number
3. Ordering Practitioner/Provider
4. Diagnosis
5. Name of Requested Equipment, MA Fee Schedule Code, Cost
6. Is this a Purchase or a Rental Request?
7. Amount of Items Requested—Over What Period of Time (if requesting rental)
8. Clinical Information to Support the Request

To obtain approval for durable medical equipment, please call Gateway’s Utilization Management Department at 1-800-392-1146 Option #3.

Should a member be in need of admission to a nursing facility, the primary care practitioner, attending practitioner, hospital Utilization Review Department, or the nursing facility should contact the Gateway Utilization Management Department at 1-800-392-1146 Option #4. Gateway will coordinate the necessary arrangements between the primary care practitioner and the nursing facility to provide the member with continuity and coordination of care.

1. All physical therapy, occupational therapy, and speech therapy require an authorization from Gateway’s Utilization Management Department. The ordering provider of the therapy must contact Gateway’s Durable Medical Equipment/Therapy Team to obtain the initial authorization. When a physical, occupational, or speech therapy provider has a request for continuation of therapy services, Gateway will accept a faxed copy of the prescription signed by the ordering participating practitioner in lieu of a telephone call from the participating practitioner. The following process must be observed: The therapy provider must first call Gateway to request continuation of therapy services before faxing the prescription (blind faxes will not be accepted.) During this telephone call the therapy provider will receive information identifying which staff member’s attention the fax should be sent to.
2. The therapy provider will fax to Gateway the signed prescription and the current progress notes, plan of treatment, and goals, which support the medical necessity of the therapy services.
3. The therapy provider will be called back when the request for therapy services is approved.
4. When the request results in a denial the current appeal process remains unchanged.

When the therapy provider does not have a signed prescription, the ordering practitioner must notify Gateway of the request for continued services.

Should a member require extended care in a non-hospital facility for rehabilitation purposes, the primary care practitioner, attending practitioner, hospital, or rehabilitation facility should call the Gateway Utilization Management Department at 1-800-392-1146.  The Utilization Management Department will provide assistance in appropriate placement thus ensuring continuity and coordination of care.

Gateway encourages the use of home-based services as an alternative to hospitalization when medically appropriate in order to:

• Allow for timely and appropriate discharge from the hospital.
• Avoid unnecessary admissions of members who could effectively be treated at home.
• Permit members to receive care in greater comfort due to familiar surroundings.

Home-based services may include, but are not limited to the following type of services:

Gateway’s Care Management Department coordinates medically necessary private duty nursing services with the ordering practitioner and the home healthcare provider. The Care Management Department can be reached at 1-800-642-3550.

Please note: Gateway cannot accept bills in half-hour increments. Providers must bill in whole hours.

Gateway’s Utilization Management Department coordinates medically necessary non-private duty home healthcare needs with the ordering practitioner and the home healthcare provider. Please call Gateway’s Utilization Management Department at 1-800-392-1146. Please do not call the home healthcare provider directly. Authorization is required for all Home-based Services. The ordering practitioner is responsible for obtaining authorization.

Due to frequent interruptions of Pennsylvania Medical Assistance coverage, Gateway strongly recommends verification of eligibility if the need for an item or service extends beyond to the calendar month in which the authorization was given.

Home Infusion services require an authorization from Gateway’s Utilization Management Department. The ordering practitioner is responsible for obtaining an authorization.

Due to frequent interruptions of Pennsylvania Medial Assistance coverage, Gateway strongly recommends verification of eligibility if the need for an item or service extends beyond the calendar month in which the authorization was given.

Should a member be in need of hospice care, the primary care practitioner, attending physician, hospital Utilization Review Department, or hospice agency should contact Gateway’s Utilization Management Department. Gateway will coordinate the necessary arrangements between the primary care practitioner and the hospice provider in order to ensure continuity and coordination of care.

Due to frequent interruptions of Pennsylvania Medial Assistance coverage, Gateway strongly recommends verification of eligibility if the need for an item or service extends beyond the calendar month in which the authorization was given.

If changing to a formulary medication is not medically advisable for a member, a practitioner must initiate a Request for Nonformulary Drug Coverage by faxing the Request for Nonformulary Drug Coverage Form, found in the Forms and Reference Materials Section of this manual, to (412) 255-4544 or 1-888-245-2049 during normal business hours, or by calling 1-800- 392-1147 during off-hours and weekends. Practitioners should assure that all information on the form is available when calling. The Request for Nonformulary Drug Coverage Form can also be found in Gateway’s Drug Formulary or at Gateway’s website. The form may be photocopied. You can also request a copy of the form by calling 1-800-528-6738.

All requests for exception will receive a response within 24 hours. In the event a decision has not been made in 24 hours, Gateway will authorize a temporary supply of the nonformulary medication. For new therapies, up to a 96-hour supply may be dispensed. For ongoing therapies, a 15-day supply of the nonformulary medication must be dispensed, pending the final determination of the request.

Any new technology identified during the Utilization Management review process, and requiring authorization for implementation of the new technology will be forwarded to the Medical Director and/or Physician Advisor for authorization. If there is a question about the appropriate governmental agency approval of the technology, the Medical Director and/or Physician Advisor will investigate the status of the technology with the agency, consult appropriate specialists related to the new technology, and/or utilize the contracted services of Hayes, Inc. for information related to the new technology. If the technology has not been approved by appropriate governmental regulatory bodies, the Medical Director and/or Physician Advisor will discuss the need for the specifically requested technology with the primary care practitioner and will consult with participating specialist from the Gateway expert panel regarding the use of the new technology. If it is determined that no other approved technology is available and/or the Medical Director and/or Physician Advisor and consultants feel that the possibility for a positive outcome would be achieved with the use of the new technology, approval may be given with the stipulation that the provider obtain the necessary signatures from the member needed for any investigational treatment/procedures.