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Insurance Referrals from Managed Health Care Plans (5.04)

Insurance Referrals from Managed Health Care Plans (5.04) - Policies, Administrative, UWHC, Department Specific, Ambulatory, Fiscal and Billing

5.04

 
 5.04 Insurance Referrals from Managed Health Care Plans  
Category: UWHC Departmental Policy  
Policy Number: 5.04  
Effective Date: April 18, 2015 
Version: Revision  
Manual: Ambulatory  
Section: Fiscal/Billing (Ambulatory)  
I. PURPOSE
To establish a process for clinic personnel to follow regarding insurance referrals for patients in managed care
plans.
II. POLICY
Patients with managed care plans that require insurance referrals will not be seen without a referral unless it is
urgent or an emergency.
III. FORMS
HealthLink Referral Request Form Financial Responsibility Form (FRF), UWH #980 HMO Referral Authorization
Form(s) sent by the referring physician, the HMO, or brought by the patient
IV. PROCEDURE
A. Scheduling Visits
1. At the time an appointment is scheduled, HealthLink (HL) will indicate if the patient has insurance
coverage requiring an insurance referral. If an insurance referral is needed, patient shall be
advised to bring it at the time of the visit or have it sent to UWHC Registration (Fax # 265-5066)
by their insurance plan prior to their appointment date.
a. Patients with HMO as Secondary - Note that in situations where the HMO is secondary to other insurance such as
worker’s compensation, an insurance referral is still needed to assure coverage for any balance not covered by the
primary insurer.
b. HMO/MA Patients - HMO/MA patients must have an insurance referral in HL for the requested appointment in
order to proceed with scheduling. There is a scheduling hard stop to prevent scheduling without insurance referrals
for these patients. Schedulers should use the Referral Request Form in HL to request an insurance referral for
HMO/MA patients. These requests are handled by Admissions. After follow-up with the HMO, Admissions will
contact the scheduler with either an approval to schedule or to indicate the HMO will not approve the visit.
i. If an authorization is present or none is required, proceed to step c.
c. Nursing personnel and medical staff are responsible for reviewing the authorization and ensuring that services
ordered do not exceed the limit(s) of what has been authorized or specifically excluded (e.g. lab work, x-rays,
procedures). The insurance referral authorization detail is entered into HL and scanned into OnBase document
imaging software.

2. In closing the discussion remind the patient, “please be sure you obtain a valid insurance referral prior to your
visit, unless you are willing to accept financial responsibility for the charges resulting from the visit.” A valid
insurance referral is a written authorization signed by the primary physician and authorized by the plan office,
usually by the medical director or utilization review staff.
3. When patients are uncertain if an insurance referral is needed, they should be advised to check their member

handbook or check with their insurer as soon as possible.
a. Staff is responsible for determining the status of an authorized insurance referral from the managed care plan
physician/medical director. (See step A.1.c. for explanations of authorized insurance referral).
4. Most managed care health plans have the following requirements with which all UWHC staff should be familiar:
a. Anytime a patient is referred outside the managed care provider system (i.e. to UWHC) the patient must
have a written insurance referral authorization signed by the primary physician and authorized by the managed
care plan office, usually by a medical director or utilization review staff.

B. Registration
1. Outpatient Registration is responsible for determining the status of a patient as a member of a managed care
plan during the course of the insurance verification/pre-registration or the sign-in process. If there is not an
authorized referral, an FRF is collected. For patients covered by an HMO Commercial plan who do not stop in
Registration, scheduler will ensure there is an insurance referral attached to the visit in HL or an FRF is collected.
2. If there is no authorized insurance referral and one is required for patients covered by HMO-MA plans, but there
is an emergent need to see the patient that day, contact the Referral line (263-8773). The Referral Specialist will
process the referral to allow the patient appointment.
3. To facilitate communication with the managed care plan, scheduler will record or verify not only the name and
address of the referring physician, but also the name and address of the Primary Health Care Provider (PCP), if it's
different. Registration will also confirm the PCP during sign-in. Managed care plans always require separate Prior
Authorization for elective admissions and procedures in addition to a valid insurance referral. However, it is always
advisable to obtain or verify preauthorization for ALL services, inpatient or outpatient, and especially for costly
procedures such as MRIs. Should urgent or emergent care be provided without preauthorization, the managed
care plan should be notified as soon as possible.

V. REVIEWED AND APPROVED BY
Ambulatory Policy and Procedure Committee
Diana Huibregtse, Director, Access Services
Clinics Administration
SIGNED BY
Deborah D. Tinker, RN, MS, Director, Ambulatory Nursing