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Referral Process
1. All consultation services for any Health Right, Inc. in-network specialist is allowed (3) visits within a 6-month period without an authorization number for referrals. After the 3 visits, an authorization number is required. The Health Right Referral Form is given to the member to take to the specialist and a copy of the referral still needs to be faxed to HRI UM Department for notification purposes only. Please fax the referral form to 202-218-0379.
2. Members can still self refer for the following services: family planning, vision, dental care, and OB/GYN care. The physician must be in the Health Right network. 3. What does not require an authorization number:
The members still need a referral form when they go to obtain these services.
However, you do not need to fax the referral form to Health Right. These services will be paid without an authorization number. 4. What requires an authorization number: All outpatient procedures endoscopy, colonscopy, sigmoidostomy, sleep studies, ENG, EMG, echocardiograms, blood transfusions, EEG, myelograms, etc. (only one visit is issued for one month. All outpatient surgeries (only one visit is issued for one month) All out of network specialist visits (must be approved. Only approved when there is absolutely no one available within our network plan to administer the services. MRI and CT scans (only one visit is issued for one month) Physical, speech, and occupation therapy (an authorization is issued for one visit for evaluation only; after we receive the treatment plan of service from the therapist then we will issue more visits according to the recommendations of the therapist) Allergy shots Home health care (must have MD order) For maternity cases only; a request can by the mother, the case manager or social worker from the hospital. DME (greater than $500.00 - all must have invoices with the cost) Prosthetics and orthotic devices (greater than $500.00 - all must have invoices with the cost) Transportation (for members that require to certain therapies/procedures on a regular basis) Dialysis treatments Hospice care The physician other than the PCP requesting the services can fill out the referral form and send to UM Department for authorization. 5. What requires authorization with MD or other clinical provider documentation or plan of treatment relating to the service requested:
These authorizations are issued once we receive the MD or other clinical provider
delivering the service documentation that relates only to the service requested. 6. Global authorizations are for maternity only. Global Authorization is only issued after receipt of the OB Registration Form. These authorizations are only covered for care/services related to the pregnancy. 7. Authorization for outpatient and inpatient procedures or surgeries, PT/OT/speech, MRI and CT scans will be faxed back to the requesting physician/provider only. Please feel free to contact the Provider Relations Department at 202-218-0373, if you have any further questions regarding Health Right's Referral Process. |
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