Referrals are required for managed care services not provided by a beneficiary’s PCP. Implied or “in-house” referrals do not require formal documentation. These are for services provided by a designated covering provider (DCP). Referrals to other providers require documentation. OMS makes available a standard referral card that providers may use to verify referrals. Other examples of acceptable referrals include referral letters, hospital admittance letters, Certificates of Medical Necessity (CMN) and verbal/telephone authorizations.
All referrals to providers other than DCPs must include:
Verbal/telephone authorizations must also include the name of the individual conferring the referral/authorization.
When medically necessary, a referred to provider may refer the recipient for further managed care covered services. A further referral/authorization can only be extended within the original time frame initially authorized by the recipient's PCP (not to exceed one year) and within the original service or condition authorized.
A referral/authorization is required prior to managed care services being performed. Managed care services that are not prior-authorized or prior-directed by the PCP or DCP are considered non-covered services.