Specialty Care Practitioner

• Verifying Eligibility
• Specialty Care Office Visit
• Referrals
• Reimbursement
• Emergency Services
• Specialists Functioning as Primary Care Practitioners
• Appointment Standards

Due to frequent changes in a member’s eligibility, specialty care practitioners must verify eligibility prior to rendering services to ensure reimbursement. This can be done by calling Gateway’s telephonic eligibility verification system - Digital Voice Assistant (DIVA). DIVA can be reached by calling 1-800-642-3515, and is available 24 hours a day, seven days a week. The Pennsylvania Medical Assistance Member Eligibility Verification System (EVS) can be reached at 1-800-766-5EVS 24 hours a day, seven days a week.

Gateway members receive specialty care services from participating practitioners through a paper or telephonic referral issued by the primary care practitioner office. Gateway’s Digital Voice Assistant (DIVA) may be used by primary care practitioners and OB/GYN practitioners to issue a referral, or by specialty care practitioners to verify the existence of a valid referral by calling 1-800-642-3515.

All Gateway members must obtain a valid referral from their primary care practitioner prior to receiving specialty services except for the services that can be accessed by a self-referral. 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 ID number. If the baby does not have an ID number, the practitioner should call Gateway’s Utilization Management Department for authorization.

If additional specialty care or diagnostic testing not authorized on the original referral is needed, please contact the member’s primary care practitioner to obtain another Gateway referral. However, if the procedures are being performed on the same date of service and in the same office as indicated on the original referral, another referral is not necessary. The specialist is responsible for providing written correspondence to the member’s primary care practitioner for coordination and continuity of care.

Payment by Gateway is considered payment in full. Under no circumstance, including but not limited to non-payment by Gateway for approved services, may a provider bill, charge, collect a deposit from, seek compensation, remuneration, or reimbursement from or have any recourse against a Gateway member.

This provision does not prohibit collection of supplemental charges or copayments. Refer to the Member Benefit Limitations and Copayments Section of this manual for information on copayments. Members cannot be denied a service if they are unable to pay their copayment. Members are responsible up to a maximum of $90 for Adult MA and $180 for Adult GA every six months. Gateway will reimburse the member for any applicable copays based upon claims submission that exceed the maximum from January through June and again from July through December of each year.

This provision shall not prohibit collection of supplemental charges or copayments on Gateway's behalf made in accordance with the terms of the enrollment agreement between Gateway and the Member/subscriber/enrollee.

Practitioners may directly bill Members for non-covered services; provided, however, that prior to the provision of such non-covered services, the practitioner must inform the Member: (i) of the service(s) to be provided; (ii) that Gateway will not pay for or be liable for said services; (iii) of the Member's rights to appeal an adverse coverage decision as fully set forth in the Provider Manual; and (iv) absent a successful appeal, that Member will be financially liable for such services.

Refer to the Claims and Billing Section of this Manual for additional information regarding submission of claims.

All Gateway members are informed that they must contact their primary care practitioner for authorization prior to seeking treatment for non-life or limb threatening conditions in an emergency room. However, Gateway realizes that there are situations when a member is under the care of a specialty care practitioner for a specific condition, such as an OB/GYN during pregnancy, and the member may contact the specialist for instructions.

If a specialty care practitioner directs a member to an emergency room for treatment, the specialty care practitioner is required to immediately notify the hospital emergency room of the pending arrival of the patient for emergency services. The specialty care practitioner is required to notify the primary care practitioner of the emergency services within one (1) business day when the emergency room visit occurs over a weekend. Every effort should be made to direct members to Gateway participating hospitals.

As a result of the Commonwealth of Pennsylvania’s HealthChoices Program, specialists in the HealthChoices counties may function as a primary care practitioner for members with complex illnesses or conditions. In order for a specialist to function as a primary care practitioner, the specialist must be approved by the Gateway Medical Director.

Specialty care practitioners agree to meet Gateway's appointment standards, as follows: