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 Recipient Programs - Managed Care

Managed Care Program

PCP Referral Guidance Memorandum

The Medical Assistance Managed Care Program is based on the primary care case management model. Referrals issued by a beneficiary’s primary care provider (PCP) or covering provider to other medical providers is a key component of this managed healthcare program. Most of a beneficiary’s care falls within the realm of ‘managed care services’.

These are services that must be provided or referred to other medical providers by the PCP. Beneficiaries can self-refer for services that are exempt from these provisions such as: “true” emergency care, dental, pharmacy and family planning.

Referral: An authorization or ‘direction of care’ from a beneficiary’s PCP to another medical provider.

Referrals do not supercede other program requirements such as:

  • medical necessity,
  • eligibility,
  • program prior authorization requirements and
  • coverage limitations.

Travel distances and the availability of in-state services should be considered prior to making out-of-state referrals.

Referral Information: Information needed on a referral to another provider.

Required:

  • Recipient name,
  • referred to provider’s name,
  • services or condition,
  • time-span (not to exceed one year) or number of visits authorized,
  • PCP name,
  • PCP provider number, date and authorized signature.

Optional:

  • In addition to required information, the PCP may include other information such as: specific directions, progress notes and what services should be referred back to the PCP.

Referral Verifications: The most common way to verify a referral is the use of State provided referral cards. These cards contain the “required referral information”.

PCPs may utilize other appropriate verifications such as:

  • documented telephone referrals,
  • referral letters,
  • customized referral forms,
  • other insurance referral forms,
  • hospital admittance letters and
  • Certificates of Medical Necessity (CMN).
  • Basically, any type of documentation that contains “required referral information” will suffice.

In-house Referral: Implied or otherwise automatic referrals. Formal referral verification is not required for In-house referrals. In-house referrals occur when a beneficiary is seen by a PCP’s covering provider for primary care services with-in the same clinic (i.e. CNP, PA or other covering physician).

Outside Referral: These referrals require verification.

They are usually for services the PCP does not normally provide such as:

  • specialty care,
  • hospital care,
  • durable medical equipment,
  • home health care and
  • diabetes education.

Verification of referrals is also required for primary care provided outside of the PCP’s clinic. This usually occurs when a patient is visiting out of town and needs non-emergency medical care (usually made for one or two visits) or to facilitate a change in PCPs (usually made for a month or less).

Further Referrals: A referred provider may refer the recipient for further Medical services. Further referrals can only be extended within the original time frame initially authorized by the recipient's PCP (not to exceed one year) and for the original services or condition authorized.

Retroactive Referral: A retroactive or backdated referral is considered inappropriate. Providing verification to follow-up on a verbal authorization or direction from the PCP or covering provider made prior to the service is allowed.

Verifying Referrals: When verifying or back-tracking referrals previously received from sources other than the recipient’s PCP, the last referring provider should be contacted to confirm the authorization information. i.e.: hospital consulting services, further referred specialty services, DME, Home Health etc.

Frequently Asked Questions

Can an in-house provider initiate referrals?
Yes. In-house providers are usually a substitute for the PCP when he/she is not available and are usually given the authority from the PCP to authorize referrals. It is up to the PCP to determine the amount of referral authority granted to in-house providers. The PCP’s provider number, and not the number of the covering provider, must be provided on the referral verification.

Can someone other than the PCP sign a referral?
Yes. The PCP or in-house provider can designate a staff member to complete, sign and date referrals. The key is that the referral must be initiated by the PCP or in-house covering provider.

What should be done when a referral is requested after-the-fact?
Check with clinic providers and/or the medical record to see if the service was prior authorized or directed by the PCP or in-house covering provider. If the service was prior authorized/directed, then the referral verification can be completed and sent to the referred-to provider after the date of service.

Should a PCP provide referrals for patients he/she has not seen?
Usually no. The PCP or referred to provider may call the Division of Medical Services if a recipient is actually receiving their primary care from a different PCP.

Contact Information

If you have questions regarding referral procedures, contact the Division of Medical Services at (605) 773-3495 or email at Medical@state.sd.us.