REFERRAL QUESTIONS AND ANSWERS

These questions and answers are in preparation for the implementation of the Referral Requirement effective November 1, 2006.

Q. Do MA enrollees NOT in ACCESS Plus require referrals?
A. No

• PCP assignments and referrals for specialty care are required only for MA recipients who are enrolled in ACCESS Plus.
• MA recipients who are not eligible for ACCESS Plus or who are awaiting enrollment through the Fee for Service system can receive services from any provider enrolled in the MA program without a PCP assignment or a referral for specialty care.
• EVS will identify recipients as ACCESS Plus enrollees.

Q. What recipients are excluded from ACCESS Plus?
A. The following are excluded from ACCESS Plus

• Individuals who are age 21 or older who receive both Medical Assistance and Medicare (dual eligible).
• Individuals who live in nursing homes or public Intermediate Care Facilities for the Mentally Retarded (ICFs/MR).
• Individuals who are enrolled in Voluntary Managed Care Plans (MCO’s).
• Children who are in substitute care out of state or out of the ACCESS Plus service area.
• Individuals in out-of-state placements.
• Individuals who become eligible for MA retroactively (for the period of retroactive eligibility).
• Individuals enrolled in the HIPP (the Health Insurance Premium Payment Program) who have HMO coverage only.

Q. Does the referral process replace prior authorization?
A. No, the ACCESS Plus PCP referral process does not replace prior authorization. Services that currently require prior authorization will continue to do so. Providers should submit proof of the PCP referral with the prior authorization request. This proof will be the PCP’s 13 digit PROMISe provider ID number and should be included in item 29 on the MA 97 form.

Q. Will enrollees still use vouchers?
A. The use of paper vouchers has been eliminated. For information on how to use the Eligibility Verification System (EVS) to validate the number of visits remaining for a recipient based on paid claims data contained within PROMISe please see Medical Assistance Bulletin 99-07-10. Visits to an ACCESS Plus Enrollee’s Primary Care Physician (PCP)or PCP referred specialist that exceed the 18 visit limit are automatically approved for a Benefit Limit Exception by the Department and do not require an additional request unless the visit is to an optometrist, chiropractor or podiatrist.

Q. What is the PCP Referral Code?
A. The recipient’s ACCESS Plus PCPs 13-digit provider number is considered the referral code. It is the PCP’s 13-digit PROMISe provider ID #. For PCP’s that are part of a group practice, the referral code is the group’s 13-digit PROMISe provider ID number.

Q. How does a PCP refer an enrollee for specialty services?
A. PCP’s should continue their current office practice for referring enrollees for specialty services. The PCP will need to give the specialist his or her 13-digit PROMISe provider ID number or, if part of a group practice, the group’s 13-digit PROMISe provider ID number. This information can be given by either phone or written format. The referral for specialty services, as well as the reason, date of referral and length of time should be notated in the patient’s medical record.

Q. Will DPW provide PCP’s Medical Assistance numbers to billing offices?
A. PCP referral numbers will not be made public. An office should never use a PCP referral number simply because it is available. The PCP acts as the medical home for the enrollee and must be consulted on every referral and should be its originator. A specialty office can contact the PCP to get approval for a referral and to get the PCP’s referral number, but the PCP must always order and approve the referral and make a note of it in the patient’s chart.

Q. What is the procedure for a patient who is "locked in" to a PCP?
A. The PCP will follow the same referral procedures for specialty services needed by the lock-in recipient. The PCP must also complete the MA45 form, Medical Assistance Restricted Recipient Referral, and forward it to the specialist. The specialist must attach the MA45 to the claim submission in order to receive payment.

Q. Will PCP's in the same group be able to see each other’s patients without a referral?
A. Yes. If the recipient’s PCP is a group then the recipient may see any enrolled individual PCP within the group without a referral.

Q. Will group practices need to give referrals to their own specialists?
A. Yes, a referral will be needed.

Q. Do Family Planning or Obstetrical/Gynecological Services require a referral?
A. No, a PCP referral is NOT needed for family planning and ob/gyn services.

Q. Do Radiology and Lab Services require a referral from a PCP?
A. No, a referral is not needed.

Q. Do eye exams require a referral from a PCP?
A. Eye care is excluded from ACCESS Plus referral requirements; however, eye care related office visits are subject to the 18-visits per fiscal year budget limits.

Billing Questions & Answers

Q. Why did Edit 752 post on my claim?
A. Edit 752 will post on a professional claim or a claim from an outpatient hospital when the referral code is missing on the claim (i.e., the ACCESS Plus PCPs 13-digit PROMISe provider ID number, denoting that a referral was granted).
If the service you are providing requires a referral from an ACCESS Plus recipient’s PCP, the referral code must be included in the referring field on the claim. For claim submission purposes, the referral code is considered the recipient’s ACCESS Plus PCPs 13-digit PROMISe provider ID number.
The following explains how to submit your claim based on claim media:

Professional Claims:

1. CMS-1500 Claim Form (Paper) – If you obtained a referral from the recipient’s ACCESS Plus PCP, enter the PCPs 13-digit PROMISe provider ID number in Block 17a (I.D. Number of Referring Physician) of a paper claim;
2. Internet Professional Claim – If you obtained a referral from the recipient’s PCP, enter the PCPs 13-digit PROMISe provider ID number in the field entitled ‘Referring Physician’ in the Service Information Section of the claim;
3. 837Professional Claim (Electronic Format) – If submitting the referring at the header, enter the PCPs 13-digit PROMISe provider ID number in entered Loop 2310A. If submitting the referring at the detail, the referring physician would be entered in Loop 2420F.

Outpatient Hospitals:

1. UB-92 Claim Form (Paper) – If you obtained a referral from the recipient’s ACCESS Plus PCP, enter the PCPs 13-digit PROMISe provider ID number in Form Locator 83, second Other Phys ID field;
2. 837I for Outpatient Claims (Electronic Format) – If you obtained a referral from the recipient’s ACCESS Plus PCP, enter the PCPs 13-digit PROMISe provider ID number in Loop 2310C, entitled Other Provider Name;
3. Internet Outpatient Claim – If you obtained a referral from the recipient’s ACCESS Plus PCP, enter the PCPs 13-digit PROMISe provider ID number in Other Provider ID field in the Service Information Section.

Please note that receipt of Edit 752 will cause a claim to suspend and deny.

Q. Why did Edit 753 post on my claim?
A. Edit 753 will post on a professional claim or a claim from an outpatient hospital when the field contains a license number or an invalid referral code (i.e., the ACCESS Plus PCPs 13-digit PROMISe provider ID number, denoting that a referral was granted) for a service that requires a referral from.
If the service you are providing requires a referral from an ACCESS Plus recipient’s PCP, the referral code must be included in the referring field on the claim (see above for claim specific field completion instructions). For claim submission purposes, the referral code is considered the recipient’s ACCESS Plus PCPs 13-digit PROMISe provider ID number.
The following explains how to submit your claim based on claim media:

Professional Claims:

1. CMS-1500 Claim Form (Paper) – If you obtained a referral from the recipient’s ACCESS Plus PCP, enter the PCPs 13-digit PROMISe provider ID number in Block 17a (I.D. Number of Referring Physician) of a paper claim;
2. Internet Professional Claim – If you obtained a referral from the recipient’s PCP, enter the PCPs 13-digit PROMISe provider ID number in the field entitled ‘Referring Physician’ in the Service Information Section of the claim;
3. 837Professional Claim (Electronic Format) – If submitting the referring at the header, enter the PCPs 13-digit PROMISe provider ID number in entered Loop 2310A. If submitting the referring at the detail, the referring physician would be entered in Loop 2420F.

Outpatient Hospitals:

1. UB-92 Claim Form (Paper) – If you obtained a referral from the recipient’s ACCESS Plus PCP, enter the PCPs 13-digit PROMISe provider ID number in Form Locator 83, second Other Phys ID field;
2. 837I for Outpatient Claims (Electronic Format) – If you obtained a referral from the recipient’s ACCESS Plus PCP, enter the PCPs 13-digit PROMISe provider ID number in Loop 2310C, entitled Other Provider Name;
3. Internet Outpatient Claim – If you obtained a referral from the recipient’s ACCESS Plus PCP, enter the PCPs 13-digit PROMISe provider ID number in Other Provider ID field in the Service Information Section.

Please note that receipt of Edit 753 will cause a claim to suspend and deny.

Q. Why did post Edit 750 post on my claim (Professional Services)?
A. Edit 750 will post on a professional claim (CMS-1500, 837P, or Professional Internet claim) when a the referring field (Block 17a of the CMS-1500, Referring Physician field on a Professional Internet claim, or the Referring field on an 837P) is completed with the PCPs PROMISe provider ID number and all 13-digits of the PCPs PROMISe provider ID number were not included in the field.
If the service you are providing requires a referral from an ACCESS Plus recipient’s PCP, the referral code must be included in the referring field on the claim (see above for claim specific field completion instructions). For claim submission purposes, the referral code is considered the recipient’s ACCESS Plus PCPs 13-digit PROMISe provider ID number.
Please note that receipt of Edit 750 will cause a claim to suspend and deny.

Q. Why did Edit 386 post on my claim (Outpatient Hospitals)?
A. Edit 386 will post on a claim from an outpatient hospital when the referring field (Other Provider ID on an Internet Claim or 837I or Form Locator 83, the second Other Physician ID field) is completed with the PCPs PROMISe provider ID number and all 13-digits of the PCPs PROMISe provider ID number were not included in the field.
If the service you are providing requires a referral from an ACCESS Plus recipient’s PCP, the referral code must be included in the referring field on the claim (see above for claim specific field completion instructions). For claim submission purposes, the referral code is considered the recipient’s ACCESS Plus PCPs 13-digit PROMISe provider ID number.
Please note that receipt of Edit 386 will cause a claim to suspend and deny.

Q. Why did Edit 754 post on my claim?
A. Edit 754 is an informational edit (i.e., the edit will not cause the claim to deny) that will post on a claim when a recipient receives a service from an ACCESS Plus PCP other than the recipient’s PCP of record.

Q. Why did Edit 755 post on my claim?
A. Edit 755 is an informational edit (i.e., the edit will not cause the claim to deny) that will post on a claim when an ACCESS Plus recipient is not assigned.

Additional Information

Q. Where can I get more information about the Referral Process?
A. The OMAP website at www.dpw.state.pa.us/omap and Bulletin Number #99-06-11 are a good source of information. Providers can also call the appropriate Promise toll-free number for their provider type:

Q. How can I become an ACCESS Plus PCP?
A. Physicians, Certified Registered Nurse Practitioners (CRNP’s), Certified Nurse Midwives and Clinics can serve as ACCESS Plus PCP’s. Specialty providers can also serve as PCP’s for individual ACCESS Plus enrollees. For more information, call the ACCESS Plus Provider Helpline at 1-800-892-1028.