Referrals and Authorizations

Referrals are necessary in order to preserve the primary care practitioner's Gatekeeper relationship with the patient. Referrals allow the primary care practitioner to approve specialty services for members on their panel.

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.

Primary Care Practitioner

Referrals must be made to an in-network Gateway specialist. Only under special circumstances can a primary care practitioner refer a member to an out-of-network provider. All out-of-network referrals require prior-authorization through Gateway's Utilization Management Department. Authorization is not required for emergency services or renal dialysis services (when the member is temporarily outside the plan's service area) provided by an out-of-network provider. Please refer to the Authorization Section of this manual for further information on the authorization process.

To issue a referral, document the referral in the patient's medical record including the number of visits or length of time of each referral. Primary care practitioners are not required to use a specific Referral Form for submission to the specialist or Gateway. Notification to the specialist is necessary, but can be made verbally or through a script given to the patient.

Specialty Care Practitioners

When a Gateway member schedules an appointment with a specialist, the office should remind the member that a referral from their 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 from the primary care practitioner, either through a written script or letter, or verbal confirmation provided by the primary care practitioner. This referral should be documented in the patient's medical record.

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 notation in the patient's record to assure continuity and coordination of care. The primary care practitioner can then issue additional referrals based upon the recommendations of the specialty care practitioner.

Except for OB/GYN providers, a specialist CANNOT refer a patient to another specialist. The primary care practitioner or the woman's OB/GYN provider must refer the member to another specialist. If a specialist recommends that another specialist should see the patient, the specialist must contact the referring primary care practitioner or OB/GYN, and the primary care practitioner or OB/GYN may then examine the patient and/or review the consult report prior to referring the patient to another specialist.

Referral form submission and referral numbers are NOT necessary when submitting claims for specialty care services.

Out-of-Plan Referrals

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.

Referrals for Second Opinions

Second opinions from a qualified health care professional may be requested by a member. When requesting a second opinion consultation, Gateway recommends that you issue a referral to an in-network qualified health care professional that is not in practice with the practitioner who rendered the first opinion. If an in-network, qualified health care professional is not available, contact Gateway's Utilization Management Department to assist in arranging for the second opinion of an out-of-network provider and obtaining authorization for the service.

Self-Referral

Members may refer themselves for the following types of care:

Routine Women's Health Care
Pap Smears
Pelvic Exams
Mammograms
Flu Shots
Pneumonia Vaccinations
Specialists Visits
Prostate Screening
Colorectal Screening
Bone Mass Measurements (Bone densitometry requires authorization by NIA)
Diabetes Monitoring Training
Vision Exams
Hearing Exams

Authorizations

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 may benefit from case management or disease management. Authorization is the responsibility of the admitting practitioner or ordering provider and can be obtained by calling Gateway Health Plan's Utilization Management Department. (Refer to the section listed as the Process for Requesting Prior Authorization.) Gateway's Medicare Assured^® HMO Utilization Management Department assesses the medical appropriateness of services using nationally-recognized criteria, such as the Managed Care Appropriateness Protocol (MCAP), and Interqual's Procedure Criteria, the Centers for Medicare and Medicaid Services' (CMS) definition of medical necessity and CMS National and Local Coverage Determinations when authorizing the delivery of healthcare services to plan members.

The CMS definition of medically necessary specifically states that a service must be medically necessary to be covered, which means that it must be reasonable and necessary for the purpose of diagnosing or treating illness or injury to improve the functioning of a malformed body member. It refers to services or supplies that: are proper and needed for the diagnosis or treatment of the member's medical condition; are used for the diagnosis, direct care, and treatment of the member's medical condition; meet the standards of good medical practice in the local community; and are not mainly for the convenience of the member or the doctor.

Process for Requesting Prior Authorizations

The Utilization Management Department is committed to assuring prompt, efficient delivery of healthcare services and to monitor quality of care provided to Gateway Health Plan Medicare Assured^® HMO members. The Utilization Management Department can be contacted between the hours of 8:30 AM and 4:30 PM, Monday through Friday.(Refer to the Quick Reference section in this manual for phone number.) 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 or questions are directed to call 1-800-685-5209. A Gateway Health Plan Medicare Assured^® HMO Medical Director is available for review of these requests when necessary.

If faxing information, speak with a Utilization Management Representative first and when requested, fax the information to the Utilization Management Representative's attention. The Representative will inform you of the name and fax number.

Authorization is the responsibility of the admitting practitioner or ordering provider. If a service requires authorization and is being requested by a specialist, the specialist's office may call Gateway to authorize the service. Hospitals may verify authorization by calling the Gateway Health Plan's Utilization Management Department. Physical, occupational or speech therapy requires authorization by the ordering practitioner or the primary care practitioner. When requesting authorization of elective procedures, Gateway recommends calling the Utilization Management Department two (2) working days in advance when possible.

When a call is received, the information given 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.

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

Member Name and Birthdate
Gateway Health Plan Medicare Assured^® HMO ID Number
Procedure Code, if applicable (CPT4, HCPCS)
DME Codes and Cost of Item(s), when applicable
Date of Service
Name of Admitting/Treating Practitioner
Name of the Practitioner requesting the Service
Practitioner's Gateway ID Number
Any other pertinent clinical information such as:
- Diagnoses/Co-morbidities
- Age
- Complications
- Progress of treatment
- Medical history
- Previous test results
- Current medications
- Psychosocial situation
- Home environment/social situation, when applicable.

When Utilization Management has authorized services provided by a Skilled Nursing Facility (SNF), Home Health Agency (HHA), or Comprehensive Outpatient Rehabilitation Facility (CORF) and it has been determined that coverage for the services will end, the Utilization Management staff will coordinate with the SNF, HHA, or CORF through a process agreed upon by the facility/agency and Gateway to provide the appropriate notification (Notice of Medicare Non-Coverage) to the member. The notification will inform the member of the discontinuation of the service and will be provided to the member within the timeframes established by CMS. (Refer to the Forms and Reference Materials section for a Notice of Medicare Non-Coverage.) Signed notifications must also be faxed to Gateway Utilization Management at 1-800-685-5231.

Speech Therapy and Hearing Services

The Utilization Management Department may request a plan of treatment for a speech therapy or hearing service request. The plan of treatment should include the following information:

Examination and evaluation results which support the use of therapy interventions
Functional assessments/evaluation
Objective physical and functional limitations
Number, frequency and modalities and or procedures, required to achieve measurable goals
Plan of treatment including any revisions
Name of the ordering physician
Prognosis for potential restoration of function in a reasonable period of time
Patient's physical progress toward measurable goals
Medical necessity of services

Physical and Occupational Therapy

The Utilization Management Department may request a plan of treatment for a physical therapy and occupational therapy request. The plan of treatment may include the following information:

Examination and evaluation results which support the use of therapy interventions
Functional assessments/evaluation
Objective physical and functional limitations
Type of treatment to be used including body areas to be treated
Number, frequency and modalities and or procedures required to achieve measurable goals
Prognosis for potential restoration of function in a reasonable period of time
Member's physical progress toward measurable goals
Revisions to original plan of treatment
Medical necessity of services.

Note: In 2006, Original Medicare imposed a financial limit of about $1,740 on the amount of care received from independently practicing physical, speech and occupational therapists. Gateway Health Plan Medicare Assured^® HMO limits therapy coverage in a similar manner. However, under both Original Medicare and Gateway Health Plan Medicare Assured^® HMO, you are permitted to get therapy you need from an outpatient hospital department without financial limitation.

Durable Medical Equipment

For DME, medical supplies and orthotics and prosthetics the following information is needed when requesting authorization:

Name of requested equipment or medical supply, appropriate code (HCPCS), cost
Rental vs. purchase request
Amount of items requested—Over what period of time (if requesting rental)
Clinical Information to Support the medically necessary service request

Services Requiring Authorization

Utilization Management prior authorization is required on the following services:

Elective Inpatient Admissions (including rehabilitation, skilled nursing facility and long-term care hospital)
Short Procedures Unit/Ambulatory Surgery Center
Durable Medical Equipment (DME), Orthotic & Prosthetic Services and Medical Supplies $500 or greater
Home Health Services
Chiropractic Services (Chiropractic services are covered to correct a subluxation by means of manual manipulation of the spine)
Outpatient Rehab (physical therapy, occupational therapy, speech therapy and cardiac rehab)
Non-emergent Ambulance Transportation
Experimental/Investigational Services
Cosmetic Services
Non-participating provider (exception: emergency room; dialysis, emergency ambulance transport)

Urgent/emergent admissions require notification to the Utilization Management Department by the next business day.

Organ transplants require prior authorization and must be performed at a Medicare-approved transplant center, per CMS requirements. The following types of transplants are covered: corneal, kidney, pancreas, liver, heart, lung, heart-lung, bone marrow, intestinal/multivisceral, and stem cell.

Requests for elective or emergent inpatient or outpatient psychiatric partial hospitalization and substance abuse services for Medicare Assured^® HMO members requiring prior authorization are called to the Member Services Department within Community Behavioral Healthcare Network of Pennsylvania (CBHNP) at 1-866-755-7299. CBHNP staff is available 24 hours a day, 7 days a week.

Requests for select outpatient elective radiological services require prior authorization. These requests must be called to National Imaging Associates (NIA), Monday through Friday from 8:00 a.m. to 8:00 p.m. (Refer to the Quick Reference section of this manual for the phone number). NIA requires authorization for the following services:

CT
MRI/MRA
Bone Densitometry
Nuclear Cardiology
PET Scans

Requests for select vision services requiring coordination for prior authorization are called to Davis Vision at 1-800-933-9371, Monday through Friday from 8:00 AM to 6:00 PM.

Prior Authorization Decision Timeframes and Notification

Standard Decisions:

For precertification requests, Gateway Health Plan^® Utilization Management Department will make a decision to approve, deny or limit authorization of the service request as expeditiously as the member's health condition requires, but no later than 14 calendar days from the receipt of the request. The Utilization Management Department will notify the requesting provider in written notification on all medical necessity denial or limited authorization determinations no later than 14 calendar days from the receipt of the request.

For urgent precertification requests, Gateway Health Plan^® Utilization Management Department will make a decision to approve, deny or limit authorization of the service request as expeditiously as the member's health condition requires, but no later than 72 hours from the receipt of the request. The Utilization Management Department will notify the requesting provider in written notification on all medical necessity denial or limited authorization determinations. Written notification will occur within 3 calendar days from the decision.

For concurrent review requests, Gateway Health Plan^® Utilization Management Department will make a decision to approve, deny or limit authorization of the service request as expeditiously as the member's health condition requires but no later than 24 hours from receipt of request for service. The Utilization Management Department will notify the requesting provider in written notification on all medical necessity denial or limited authorization determinations. Written notification will occur within 3 calendar days from the decision.

For medical necessity denial or limited authorization determinations, the Utilization Management Department will instruct the requesting provider on how to contact the Physician Advisor for a peer review discussion.

Expedited Decisions:

For expedited requests, Gateway Health Plan^® Utilization Management Department will make a decision to approve, deny or limit authorization of the service request as expeditiously as the member's health condition requires, but no later than 72 hours from the receipt of the request. The Utilization Management Department will notify the requesting provider in written notification on all medical necessity denial or limited authorization determinations. Written notification will occur within 3 calendar days from the decision.

Home Infusion

Requests for home infusion medications may be called or faxed into Gateway's Pharmacy Department. Faxed requests should be on the Home Infusion Drug Request Form, which can be found in the Forms and Reference Material Section of this Manual. The completed form should contain the following information: Drug name, dose, frequency and duration requested; diagnosis; provider of service for the nursing visits, and medical supplies related to the infusion. If the requested drug is a non-formulary drug, the request form should also include formulary medications tried and failed or medical rationale for non-formulary drug.

Please Note: Formulary IV antibiotics do not require authorization from the Pharmacy Department. Please call the Utilization Management directly to obtain nursing visit and supply authorization. The medications will adjudicate automatically on-line through our claims processor (Argus).

Gateway's Pharmacy Department will review the request for the drug to be administered via home infusion.

If approved, an electronic authorization will be entered. No authorization number for the drug is needed. Gateway's Pharmacy Department will notify the requesting physician of the final decision.

Gateway's Pharmacy Department will notify the Utilization Management Department of the drug authorization. Gateway's Utilization Management will then contact the infusion provider with the authorization number for the per diem rate for the supplies as well as one nursing visit per week and any additional nursing visits noted on the Home Infusion Drug Request Form. The authorization will be for the same duration that the Pharmacy Department has approved the drug.

If additional nursing visits are needed the provider must contact Gateway's Utilization Management Department to obtain the authorization.

If the approved drug therapy is to continue for a longer duration than initially authorized, the provider must contact Gateway's Pharmacy Department to obtain additional authorization.

Pennsylvania Important Phone numbers:
Pharmacy Phone: 1-800-685-5215
Pharmacy Fax: 1-888-245-2049
Utilization Management Phone: 1-800-685-5207

Infused enteral products are covered up to $500 without an authorization. A separate authorization from Gateway's Utilization Management Department for the infusion services is required.

Pharmacy Services

Gateway Health Plan^® utilizes a closed formulary. Physicians are encouraged to prescribe formulary medications when medically appropriate. If changing to a formulary medication is not medically advisable for a member, a practitioner must initiate a Request for Non-formulary Drug Coverage by faxing the Request for Non-formulary Drug Exception 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 the Gateway Health Plan^® Pharmacy, during off-hours and weekends. (Refer to the Quick Reference section in this manual for phone number.) Practitioners should assure that all information on the form is available when calling. The Request for Non-formulary Drug Exception Form can also be found on Gateway's website. The form may be photocopied. You can also request a copy of the form by calling the Gateway Health Plan^® Pharmacy Department.

All requests submitted with the necessary clinical information will be reviewed and a decision made as expeditiously as the member's health condition requires, but no later than 72 hours after receipt of the request by Gateway Health Plan^® Pharmacy Department.

If the drug is an ongoing drug, the Gateway Health Plan Pharmacy Department will authorize up to a 30-day supply of the drug to provide coverage during the review process and allow for sufficient time to transition the member to a formulary alternative.

New Technology

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. The technology will also be investigated through CMS National and Local Coverage Determinations. 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. The new technology review will be presented to the Gateway QI/UM Committee. 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. Gateway will consider those specific medical items, services, treatment procedures or technologies not specifically identified as non-covered or non-reimbursable by Medicare as defined within National Coverage Determinations.