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There are a number of outpatient services included in designated
(capitated) programs for commercial HMO and POS
members. These services are:
- diagnostic radiology
- short-term rehabilitation
- laboratory
Primary care physicians (PCP) must refer most HMO/POS members to their
capitated site for these specialty
services. In addition, participating specialists
must refer HMO
and POS members to the capitated sites of the
member's PCP. The member's capitated laboratory site is indicated on his/her
member ID card. You may obtain
additional specialty site information for the member's PCP on the
NaviNet
® web portal by using the Eligibility and
Benefits Inquiry transaction.
Pennsylvania
- For HMO/POS members, all radiology referrals must be to the PCP's capitated
site.
- For HMO/POS members, all short-term rehabilitation and outpatient
laboratory and referrals must be to the PCP's
capitated site.
- For Direct POS members, no referrals are required for members to see
participating specialists. However, referrals
are required for routine radiology (except mammograms), spinal manipulation,
and physical/occupational therapy
services. To receive the highest level of benefits, members should be referred
to the PCP's capitated site for
capitated services (i.e., radiology, physical/occupational therapy, and
laboratory).
New Jersey
- There are no capitation requirements for radiology for AmeriHealth New
Jersey members.
- For HMO/POS members, all short-term rehabilitation and outpatient
laboratory referrals should be to the
PCP's capitated site.
- HMO/POS members may choose to select a site other than the PCP's capitated
site for these specialty services.
Should the member choose to receive services you have authorized from a
participating provider or facility
other than the PCP's capitated site, you will need to issue a referral and may
refer to any participating provider;
preapproval is not required.
For more information regarding member referrals to capitated sites, please
refer to the Specialty Programs section of
the Provider Manual for Participating Professional Providers
(Manual)*.
If you have any questions, please contact your Provider Partnership
Associate or your Network Coordinator.
*An updated version of
the Manual for New Jersey providers will be
available later this month.
NaviNet is a registered trademark of NaviNet, Inc.
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