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Medical Insurance 7th Edition by Amy Blochowiak, Joanne Valerius, Nenna Bayes, Cynthia Newby
Edition 7ISBN: 978-1259683077Medical Insurance 7th Edition by Amy Blochowiak, Joanne Valerius, Nenna Bayes, Cynthia Newby
Edition 7ISBN: 978-1259683077 Exercise 7
Read the following referral policy for a payer's HMO plan and answer the questions that follow.
Referral Policy
The following points are important to remember regarding referrals:
?The referral is the way the member's PCP arranges for a member to be covered for necessary, appropriate specialty care and follow-up treatment.
?The member should discuss the referral with his or her PCP to understand what specialist services are being recommended and why.
?If the specialist recommends any additional treatments or tests that are covered benefits, the member needs to get another referral from his or her PCP prior to receiving the services. If the member does not get another referral for these services, the member may be responsible for payment.
?Except in emergencies, all hospital admissions and outpatient surgery require a prior referral from the member's PCP and prior authorization by the plan.
?If it is not an emergency and the member goes to a doctor or facility without a referral, the member must pay the bill.
?In plans without out-of-network benefits, coverage for services from nonparticipating providers requires prior authorization by the plan in addition to a special nonparticipating referral from the PCP. When properly authorized, these services are fully covered, less the applicable cost-sharing.
?The referral provides that, except for applicable cost-sharing, the member will not have to pay the charges for covered benefits as long as the individual is a member at the time the services are provided.
A. In plans with out-of-network benefits, under what three circumstances does this HMO plan require referrals from the plan member's primary care provider (PCP)?
B. What two approvals are needed for nonemergency hospital admissions and outpatient surgery?
C. If the plan does not have out-of-network benefits:
(1) Is it possible for a plan member to be covered for services from nonparticipating providers?
(2) What must the plan member do to secure coverage?
(3) What charges apply?
Referral Policy
The following points are important to remember regarding referrals:
?The referral is the way the member's PCP arranges for a member to be covered for necessary, appropriate specialty care and follow-up treatment.
?The member should discuss the referral with his or her PCP to understand what specialist services are being recommended and why.
?If the specialist recommends any additional treatments or tests that are covered benefits, the member needs to get another referral from his or her PCP prior to receiving the services. If the member does not get another referral for these services, the member may be responsible for payment.
?Except in emergencies, all hospital admissions and outpatient surgery require a prior referral from the member's PCP and prior authorization by the plan.
?If it is not an emergency and the member goes to a doctor or facility without a referral, the member must pay the bill.
?In plans without out-of-network benefits, coverage for services from nonparticipating providers requires prior authorization by the plan in addition to a special nonparticipating referral from the PCP. When properly authorized, these services are fully covered, less the applicable cost-sharing.
?The referral provides that, except for applicable cost-sharing, the member will not have to pay the charges for covered benefits as long as the individual is a member at the time the services are provided.
A. In plans with out-of-network benefits, under what three circumstances does this HMO plan require referrals from the plan member's primary care provider (PCP)?
B. What two approvals are needed for nonemergency hospital admissions and outpatient surgery?
C. If the plan does not have out-of-network benefits:
(1) Is it possible for a plan member to be covered for services from nonparticipating providers?
(2) What must the plan member do to secure coverage?
(3) What charges apply?
Explanation
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Verified
1. A. If a specialist recommends any add...
Medical Insurance 7th Edition by Amy Blochowiak, Joanne Valerius, Nenna Bayes, Cynthia Newby
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