REFERRAL & AUTHORIZATION GUIDELINES
Total Physicians, Hospitals & Others
- Authorization Grid – Effective through March 31, 2021
- Prior Authorization Grid – Effective April 1, 2021
- High Tech Radiology List – Effective April 1, 2021
- Specialty Drugs
- Home Care Prior Authorization Form
- Home Care IV Prior Authorization Form
Inpatient Authorizations: Request authorizations for inpatient services via fax to THC Medical Management at 313-748-1312.
Other Services Requiring Authorization: Request via fax as above. Do not use the Provider Portal. Delete any requests in the portal other than for high-tech radiology requests.
Referrals: The referral process changes for dates of service April 1, 2021 and beyond. PCPs initiate referrals via the online portal. Follow current process through March 30; as of April 1, referrals are required for specific high-tech radiology tests only.
There is no alpha character for an online approved referral. Referrals do not require clinical review and approval from Total Health Care.
- Services performed within the offices of in-network specialty providers. Providers may treat as needed in office.
NOTE: Out of Network Services: Prior Authorization Required.
Referral Requirement Changes with Dates of Service 4/1/2021
EFFECTIVE WITH DATES OF SERVICE APRIL 1, 2021: No referral required for the benefit maximum of 30 visits. All services beyond the benefit maximum require a prior authorization.
EFFECTIVE JULY 1, 2019 through March 30, 2021:
•PCPs will be the gatekeepers for referrals for PT/OT/ST services. The PCP will provide the initial referral for services to include an evaluation plus treatment visits, for a maximum up to 12. This updates the current referral process of creating a referral for the evaluation only.
•Subsequent referrals may be processed in increments of a maximum of 6 visits per referral. The benefit maximum for referrals is 30 visits. Therefore, a total of 4 referrals are allowed.
•If additional visits beyond 30 are clinically indicated, clinical review and approval is required through Total Health Care’s Utilization Department. The provider of service may fax clinical information to 313-748-1312 to request visits beyond 30. The PCP is not required to initiate the request.
NOTE: Chiropractic services are a combined benefit with physical therapy for most commercial members and also require a PCP referral. Therefore, any chiropractic referrals should be deducted from the 30 visits for PT referrals. The PCP will be able to initiate the referral, but it is up to the provider of services to verify eligibility and benefits. Therefore, the referral is not a guarantee of payment.
When Referring A Patient Beyond PCP Care
- Provide concise instructions, expectations on scope of referral for both patient and specialty physician, including whether the referral is for:
- Formal consultation
- Co-management of patient
- Provide appropriate reports of prior diagnostic testing (e.g., labs, radiology, medications, progress notes)
- Be available for phone consultations
- Track patient compliance with the referral
- Set boundaries and expectations with patients concerning where and with whom they may access care, emphasizing the importance of the network to coordinate care plans
- THC supports Patient Centered Medical Home (PCMH) principles, an approach to providing comprehensive primary care that facilitates partnerships between individual patients, their physicians and families. THC expects our PCPs to direct patient care to appropriate providers with whom they have established relationships and will share care plans. Visit the Provider Search option in the Provider Portal at www.THCmi.com for a listing of contracted specialty provider.
PCP AND REFERRAL PHYSICIAN SHARE ACCOUNTABILITY FOR PATIENT CARE
- Manage utilization, including avoiding duplication of testing
- Be readily available for urgent requests when coordinating care
- Develop care plans and self-management goals with clear instructions for patient follow up
- Arrange for coverage when unavailable
You may contact THC Provider Relations at 844-THC-DOCS (844-842-3627) for questions or assistance when referring patients for care.