PA Resources Portlet
CODING & DOCUMENTATION
EDUCATION & EVENTS
ENROLLMENT & CREDENTIALING
FORMS & MANUALS
POLICIES & GUIDELINES
PROGRAMS & INITIATIVES
PROVIDER NETWORKS & SPECIALTIES
PA Dynamic Rendering
Important Information About the Personal Choice Network
- Referrals do not override contract benefits.
- Referrals and precertifications are mutually exclusive of each other. It is possible that a patient does not need a referral but does need a precertification. A predetermination may be obtained from Medical Review for certain proposed treatment plans.
- Referral – from the primary care provider (PCP) to specialist or facility
- Precertification – determines appropriateness of location of treatment
- Predetermination – determines medical necessity of proposed treatment plan
- Retro-referrals can be obtained only in the case of a PCP office error. (Specific protocol must be followed.)
- Physical therapy, speech therapy, durable medical equipment and home health (participating agencies only) do not require a referral when ordered by the PCP or specialist with a current referral.
- Chiropractors and podiatrists require referrals. (Use in-network providers only.)
- Dentists do not require a referral unless the services are temporomandibular joint (TMJ) or accident related.
- If a member's Personal Choice Network plan is secondary to another insurance plan, referrals are still required.
- All referrals must be reissued if the patient has changes his/her PCP. A PCN member may designate a new PCP up to twice per year, even if the new PCP is in the same office.
- A separate referral from the PCP is required if the referred-to specialist sends the patient to another physician.
- All emergency room visits require a referral. The PCP determines the medical necessity of the ER visit prior to issuing the referral. If the member is admitted to the hospital, a referral is not required.