Additional Referral Requirements for SMI Members Clause Samples

Additional Referral Requirements for SMI Members. For SMI members receiving physical health care services, the Contractor shall: 9.7.1 Establish and implement written procedures for referrals to specialists or other services, to include, at a minimum, the following: Use of referral forms clearly identifying the Contractor; Referrals to specialty physician services shall be from a PCP, except as follows: 9.7.1.1.1 Women shall have direct access to in-network OB/GYN providers, including physicians, physician assistants and nurse practitioners within the scope of their practice, without a referral for preventive and routine services (42 CFR 438.206(b)(2)). 9.7.1.1.2 SMI members that need a specialized course of treatment or regular care monitoring shall have a mechanism for direct access to a specialist (for example through a standing referral or an approved number of visits) as appropriate for the member‘s condition and identified needs. Any waiver of this requirement by the Contractor must be approved in advance by ADHS/DBHS. A process for the member's PCP to receive all specialist and consulting reports and a process for the PCP to follow-up on all referrals. A process to refer any member who requests information or is about to lose AHCCCS eligibility or other benefits to options for low-cost or no-cost health care services. 9.7.2 Comply with all applicable physician referral requirements and conditions defined in Sections 1903(s) and 1877 of the Social Security Act and corresponding regulations which include, but are not limited to, 42 CFR Part 411, Part 424, Part 435 and Part 455. Sections 1903(s) and 1877 of the Act prohibits physicians from making referrals for designated health services to health care entities with which the physician or a member of the physician‘s family has a financial relationship. Designated health services include, at a minimum: Clinical laboratory services; Physical therapy services; Occupational therapy services; Radiology services; Radiation therapy services and supplies; Durable medical equipment and supplies; Parenteral and enteral nutrients, equipment and supplies; Prosthetics, orthotics and prosthetic devices and supplies; Home health services; Outpatient prescription drugs; and Inpatient and outpatient hospital services.