Specialty Care Practitioner
Verifying Eligibility
Specialty care practitioners must verify eligibility prior to rendering services to ensure reimbursement. Gateway’s eligibility verification line can be reached at 1-800-642-3515, 24 hours a day, seven days a week.
Referrals
All Gateway members must obtain a valid referral (a paper referral form is not required) from their primary care practitioner prior to receiving specialty services except for the services that can be accessed by self-referral. 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 and document the referral in the patient’s medical record. Primary care practitioners can issue a referral to a specialist either verbally or through a script given to the patient.
If the specialty care practitioner determines 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 medical 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.
A specialist CANNOT refer a patient to another specialist. The primary care practitioner must refer the member to another specialist. If a specialist recommends that another specialist should see the patient, 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.
Referral form submission and referral numbers are NOT necessary when submitting claims for specialty care services.
The specialist is responsible for providing written correspondence to the member’s primary care practitioner for continuity and coordination of care.
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Emergency Services
Federal and state regulations prevent us from requiring members to contact a PCP, specialist or the plan prior to seeking emergency care. The decision by a member to seek emergency care is based upon “prudent layperson” standard. Per CMS guidelines: “An emergency medical condition is a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, with an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in:
- Serious jeopardy to the health of the individual or, in the case of a pregnant woman, the health of the woman or her unborn child;
- Serious impairment to bodily functions; or
- Serious dysfunction of any bodily organ or part.
Emergency services are covered inpatient and outpatient services that are:
Furnished by a provider qualified to furnish emergency services; and needed to evaluate or stabilize an emergency medical condition.
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. Members should be directed to the closest appropriate emergency provider.
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Appointment Standards
Specialty care practitioners including Allergists, General Surgeons, Otolaryngologists, Certified Nurse Practitioners and Orthopedists agree to meet Gateway's appointment standards, as follows:
| REQUIREMENT |
STANDARD |
| Wait time for an Urgent, but Non-Emergent Care Appointment |
Within twenty-four (24) hours from the date of referral |
| Wait time for a Non-Urgent, but in need of Attention Appointment |
Within 1 week from the date of referral |
| Wait time for a Routine Care Appointment |
Within 30 days from the date of referral |
| Waiting Time in the Waiting Room |
No more than fifteen (15) minutes or up to one (1) hour when the MD encounters an unanticipated urgent visit or is treating a member with a difficult need. |
A member should be seen by a practitioner as expeditiously as the member's condition warrants, based on the severity of symptoms. If a practitioner is unable to see the member within the appropriate timeframe, Gateway will facilitate an appointment with a participating or non-participating practitioner, if necessary.
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