Referrals

PCPs must provide a referral to members of the HMO Personal Care Plan or Point- of-Service Personal Care Plan when members need to obtain specialty care services. OB/Gyns may also provide referrals when their patients who are members of a Personal Care Plan need to obtain specialty care. When the referral is to a ConnectiCare participating provider, services are payable by the health plan for HMO Personal Care Plan members, and Point-of-Service Personal Care Plan members receive a higher benefit level.

Examples of services that do require a referral:

• Chiropractic services
• Medical and surgical specialty visits, except OB/Gyn visits
• Non-routine vision services

Examples of services that do not require a referral:

• OB/Gyn services
• Routine vision care for members with vision coverage
• Emergency ambulance services (ground or air)
• Emergency services
• Walk-in/Urgent Care

Note: Services that require referral may change from time to time. ConnectiCare will notify physicians prior to the effective date of such change.

• Referrals are required only for members who have the Personal Care Plan design. The member ID cards states "REFERRAL REQUIRED" for members with a Personal Care Plan. ID cards for members in Open Access Plans state "NO REFERRAL REQUIRED."

• PCPs coordinate the member’s medical services. When a PCP provides specialty services for a member, or refers a member to another physician within his/her group practice, a referral is not required.

• Make referrals only to in-plan participating providers. Refer to the ConnectiCare Provider Directory to get specialist ID numbers. Or, go to ConnectiCare’s website to view our directory online

• If it is necessary for a member to see a specialist, the PCP is responsible for entering the referral into ConnectiCare’s Eligibility & Referral system. (Refer to Online & Automated Features for additional instruction.)

• The number of visits for which a referral is valid is determined by the PCP, based on the member’s medical need.

• Though you must enter a diagnosis code to create a referral, the diagnosis on the applicable claim(s) does not need to match the one that is originally entered.

• When deemed appropriate, the PCP may authorize a standing referral for specialty care provided by a participating provider for services that are consistent with the terms of the member's plan benefits. Since the referral is not bound by an expiration date, this may be done by entering an appropriate number of visits.

• PCP referrals to a specialist who participates in a group practice are considered valid for all physicians of that same specialty within that group practice.

• Without a valid referral in ConnectiCare's referral system, specialists claims are either denied or, for Point-of-Service Personal Care Plan members, covered at the out-of-network level of benefits.

• You must request pre-authorization - in advance and in writing - to obtain services from a non-participating provider. ConnectiCare will grant pre-authorization only when medically necessary services are not available from providers within plan. Such referrals should be made according to the plan approved by ConnectiCare, the referring PCP, and the non-participating physician. Send requests in writing via fax to (860) 674-5893 or 1-800-923-2852, or send it by mail to:

Attn:  Clinical Review Dept.
ConnectiCare
175 Scott Swamp Road
Farmington, CT  06032

See Medical Management Programs for pre-authorization procedures.

• Specialists, except for OB/GYNs may not make referrals to other specialists.

Ask members to call our Member Services Department at (860) 674-5757 or 1-800-251-7722 if they have any questions on their benefit programs.

Note: For information about mental health, alcohol, and substance abuse services, call ConnectiCare’s Behavioral Health Program at 1-800-349-5365.

PROCEDURE FOR MAKING REFERRALS

• Enter referrals through the Eligibility & Referral Line, using a touch-tone phone.

• Enter the referrals daily, if possible, but in no instance later than seven days from the date you refer the member. (This window is provided for your convenience and should not be used to accommodate members who self-refer.)

To access the Eligibility & Referral Line, call: (860) 674-5800 or 1-800-562-6834:

In addition to telephonic referral entry, referrals can also be entered and inquired on securely through the Internet using Capario. Referrals can be entered through Capario 7 days a week, 24 hours a day. To sign up for Capario referral services, please call Capario at 1-800-586-6870.

Additional details on making referrals via the Eligibility & Referral Line or Capario are provided in Automated & Online Features.

What happens next?

• Once the referral is entered, a referral number is assigned.

• The referral is automatically loaded into ConnectiCare’s claims system to be matched when the claim arrives.

• The member will receive a confirmation letter outlining the terms of the referral.

• Specialists can also verify that a referral was made by accessing the Eligibility & Referral Line and entering information as prompted or by verifying the information through Capario online services.

• Both referring physicians and specialists may opt to have a referral confirmation letter faxed to them. If using Capario, physicians can also print the Capario confirmation received through the Internet.

AFTER A REFERRAL IS MADE

• You can verify that a referral has been entered by calling ConnectiCare’s Eligibility & Referral Line or accessing Capario online services. To do so, you will need the member’s ID number and the ID number of the specialist to whom the member is being referred.

• Specialists and other practitioners who evaluate and treat ConnectiCare members are required to communicate promptly, and regularly, the results of all consultations, evaluations and treatment to the member’s PCP, including notifying the PCP when the treatment has ended.

• Subsequent referrals to other providers must be made through the member’s PCP.

• Members with the Point-of-Service Personal Care Plan, FlexPOS, or PPO Plan may access specialty care without a referral, but out-of-network benefits apply and the member is responsible for applicable deductibles and coinsurance. Without a referral, members are responsible for all services rendered that are not paid for by ConnectiCare.