Oxford Health Plans > Brokers' Resources > Medical & Administrative Policies > Referrals


Title of Medical Policy

Referrals

The services described in Oxford policies are subject to the terms, conditions and limitations of the Member's contract or certificate. Unless otherwise stated, Oxford policies do not apply to Oxford Medicare Advantage Members. Oxford reserves the right, in its sole discretion, to modify policies as necessary without prior written notice unless otherwise required by Oxford's administrative procedures. The term Oxford includes Oxford Health Plans, LLC and all of its subsidiaries as appropriate for these policies.

Certain policies may not be applicable to Self-Funded Members and certain insured products. Refer to the Member's plan of benefits or Certificate of Coverage to determine whether coverage is provided or if there are any exclusions or benefit limitations applicable to any of these policies. If there is a difference between any policy and the Member’s plan of benefits or Certificate of Coverage, the plan of benefits or Certificate of Coverage will govern.

Coverage Statement

Policy is applicable to:

    Commercial plans

    Oxford Medicare Advantage® plans, including Medicare Group Accounts (MGA)


Purpose

The purpose of this document is to discuss Oxford Health Plans® policy on Referrals for those Members who have a Gatekeeper Product.

Definitions

Gatekeeper Product - A plan which requires a Member to receive a referral from their PCP for certain network services. In most gatekeeper plans, the PCP serves as a "gatekeeper", because the Member must obtain a referral from their PCP prior to seeing any other provider.

Non-Gatekeeper Product - A plan that does not require a Member to receive a Referral from his/her PCP for certain network services.

Oxford - As used herein shall mean any affiliates of or subsidiary of Oxford Health Plan Inc., which provides access to health care services.

Primary Care Physician (PCP) - A plan physician who has the primary responsibility for providing, arranging, and coordinating all aspects of a Member's healthcare.

Participating Oxford Provider(Physician, Specialist, Hospital, Ancillary) - A health professional, a supplier of health items, or a healthcare facility having an agreement with Oxford or a Contracting Medical Group or Independent Physician Associates (IPA), to provide or coordinate medical services to specific Oxford Health Plans Members (i.e., Freedom, Liberty, Oxford Medicare Advantage).

Referral - A Referral is the recommendation by a Primary Care Physician (PCP) and/or health plan for a Member to receive care from a different Participating Oxford physician, or specialist. When an Oxford Member needs medical care that a PCP or OB/GYN cannot generally provide within the scope of his/her practice, a Referral can be generated for services to a Participating Oxford-Specialist, Hospital, or other Ancillary Provider. Only PCP's, OBGYN's or certain limited specialist as described on page three of this policy may issue referrals. Referrals made by any other provider not listed here will not be considered in network.

Precertification - An authorization given by Oxford that must be received before the Member can obtain certain Covered Services.

Policy

When an Oxford Member needs medical care that a PCP or OB/GYN cannot generally provide within the scope of his/her practice, an Oxford Referral can be generated for services to a Participating Oxford Specialist, Hospital, or other Ancillary Provider within the applicable network of providers available to the Member.

An Oxford Referral allows a Member of a gatekeeper product to receive services from a Participating Oxford Specialist on an in-network basis.

Members of non-gatekeeper products do not need Referrals to see Participating Oxford Specialists on an in-network basis. However, Members of certain non-gatekeeper products require Precertification for outpatient mental health services, refer to Outpatient Mental Health for Commercial Members.

*A Member's PCP is defined as a family practitioner, general practitioner, internist, or pediatrician. In addition, Participating Oxford Specialists may act as a Member's PCP if approved and authorized by Oxford. Refer to Selection of a Primary Care Physician (PCP).

An Oxford Referral does not guarantee that Oxford will cover the services provided by the Participating Oxford specialist. Covered services are subject to:

  • Medical necessity, as determined by Oxford's medical policies,
  • Member eligibility on the date(s) of service, and
  • Member's benefits as defined in the conditions, terms and limitations of their Summary of Benefits/Certificates/Contract.

  1. Who can issue Referrals
    An Oxford Referral to a Participating Oxford Specialist, Hospital, or Ancillary Provider can be issued by any Participating Oxford PCP or OB/GYN. Participating Oxford Specialists can only issue Referrals for certain types of covered services as outlined in the grid below:

    If you are Then you can submit
    Referrals* for:
    Any Participating Oxford Specialist Any diagnostic procedure***
    A Participating Oxford PCP**, General Surgeon**, Gynecological Oncologist**, Hematologist-Oncologist**, Neurologist**, Oncologist**, Orthopedists**, Pain Management Specialist, Physiatrist**, Neurosurgeon**, Rheumatologist**, Chiropractor Any diagnostic procedure, as well as therapeutic services***, such as physical and occupational therapy (for Commercial Products)
    A Participating Oxford Nephrologist**, Oncologist**, Infectious disease (HIV) Specialist** All specialist care***

    *Please note exceptions to the Referral requirements at the end of this policy. **Adult or pediatric.
    ***Precertification guidelines still apply for those covered services that require Precertification (i.e.,Outpatient Physical/Occupational Therapy Services for Oxford Medicare Advantage. In addition, the Referral must be to a Participating Oxford Provider within the Member's applicable network.

    If the Participating Oxford Provider has never seen the Member before, the Participating Oxford Provider has the right to ask the Member to come in for an examination and diagnosis before issuing an Oxford Referral. In an existing Participating Oxford Provider/Member relationship, if a Member requests an Oxford Referral and the Participating Oxford Provider believes the Referral is appropriate, an Oxford Referral may be generated without seeing the Member. This would be done entirely at the discretion of the Participating Oxford Provider.

    Oxford On-Call may issue an urgent, same day Referral when a Member calls and is experiencing urgent medical symptoms.

    Oxford's Behavioral Health Department can issue an Oxford Referral directly to the Member if s/he is uncomfortable approaching his/her PCP for a Referral to a Participating Oxford Behavioral Health Specialist.

  2. Parameters of Referrals
    An Oxford Referral is issued for a defined time period and for a maximum quantity of services, as defined by the referring physician. If not defined, an Oxford Referral is valid for 1 visit within 180 days (6 months) of the date the referral was issued. When a physician indicates both a time limit and a number of visits, the Referral defaults to whichever comes first.

      Example: If 6 months and 4 visits are selected, and the patient utilizes 4 visits in 3 months, s/he would need another Referral for more services.

    The maximum number of visits for which a Referral can be generated is 30 visits within 180 days (6 months). If more visits are necessary within this timeframe, another Referral must be generated.

    Oxford's Medical Management Department may approve standing Referrals to Participating Oxford Specialists or Ancillary Providers for those Members who may require ongoing specialist treatment. Standing Referrals are provided when the Participating Oxford Provider is requesting greater than thirty visits within a six month period, or covered services beyond a six month period, but less than twelve months. This may be applicable to any Member with a life threatening or degenerative and disabling condition (i.e., complex medical condition).

    When a benefit is limited to a number of visits, the service will be covered up to the benefit limitation as stated in the applicable Member certificate (Summary of Benefits, Evidence of Coverage, et al), and not the timeframe specified in the Referral.

    An Oxford Referral can be transferred to and honored for a different provider than originally indicated on the referral, and would be payable in-network if the provider:

      1. Is a Participating Oxford Provider for the Member's network, and
      2. Has the same specialty or specialty grouping as the original referred to provider.

Oxford Referrals should not be issued for services already provided. In cases where the Participating Oxford Provider is administratively unable to submit a Referral prior to the services being rendered, Oxford will allow the Referral to be generated up to 72 hours after the services were rendered. Oxford will not pay for claims of services arising out of prohibited physician self-referrals. Prohibited Referrals are defined by applicable law and include but are not limited to instances where a provider or the provider's relative have a financial interest in the Referral. For additional information, refer to:Providers Caring for Themselves or Relatives . Oxford reserves the right to monitor retroactive referral generation and compliance with this policy.

Exception: Chiropractic services and PT/OT services:
  1. For all Connecticut Oxford Medicare Advantage Members and, for most Commercial Members: A Referral for in-network chiropractic care is required for the initial visit only, referrals for Chiropractic and PT/OT services are valid for 1 visit only; Services rendered subsequent to the initial visit must be precertified. Refer to the following policies for more details:
    • In Office Chiropractic Services for Commercial Members
    • In Office Chiropractic Services for the TRIAD Commercial Members
    • Chiropractic Services for Oxford Medicare Advantage

  2. For all Connecticut Oxford Medicare Advantage Members and most Commercial Members, a Referral for in-network outpatient PT/OT services is good for the initial visit (evaluation) only. Precertification is required for subsequent visits. Please refer to:

    • Outpatient Physical and Occupational Therapy (OrthoNet Arrangement).
    • Outpatient Physical/Occupational Therapy Services for Oxford Medicare Advantage

  1. How Referrals are submitted
    An Oxford Referral must be submitted electronically to Oxford for all Oxford Members.

The options available for submitting a Referral to Oxford electronically are through:
  • Oxford Express, Oxford's automated phone system, at 1-800-666-1353.
  • Envoy point-of-service terminal or Enline companion software (i.e. through electronic data submission, or EDI), or
  • http://oxfordhealth.com for Commercial Members only.

Once submitted, the referring provider should communicate the reference number of the Referral to the Member. The Member can bring this to the specialist or the specialist can directly confirm a Referral is on file through oxfordhealth.com (for commercial Members only), through Oxford Express or through an envoy-point-of-service terminal.

Procedures and Responsibilities

  1. Participating Oxford Providers
    An Oxford Referral must be submitted for covered services rendered by Participating Oxford Providers and for those covered services that do not otherwise require Precertification. An Oxford Referral cannot be submitted in lieu of Precertification for those covered services that require Precertification.

    When a claim is received from a Participating Oxford Provider, an Oxford Referral must be on-file at Oxford within 72 hours from the date of service in order for the claim to be processed in-network.

    An Oxford Referral must be made to a Participating Oxford Provider within the Member's network. For example, an Oxford Medicare Advantage Member must be referred to a Participating Oxford Provider who participates with the Oxford Medicare Advantage network and a Liberty Member must be referred to a Participating Oxford Provider who participates in the Liberty network. The network is noted on the Member's ID card.

    Services for Members who self-refer to a Participating Oxford Provider will be handled according to the following grid:

    If you are a Member of this product ...and you self-refer to a Participating Oxford Specialist, then...
    Commercial Gatekeeper plan with no out-of-network benefits Services would not be eligible for coverage
    Commercial Gatekeeper plan with out-of-network benefits Services would be eligible for out-of-network coverage (subject to plan deductible and cost share requirements)
    Commercial Non-Gatekeeper plan with or without out-of-network benefits* Services would be eligible for in-network coverage.
    All New Jersey and New York Oxford Medicare Advantage Plans, including Medicare Group Accounts (MGA) Services would be eligible for coverage.
    Connecticut Oxford Medicare Advantage Plans, including Medicare Group Accounts (MGA) with no out-of-network benefits (HMO only) Services would not be eligible for in-network coverage.

    *Members of Non-gated plans (PPO, Access,Select Plans and New York/New Jersey Oxford Medicare Advantage Plans) can self refer to Participating Oxford Providers and receive in-network coverage. A Referral from a Participating Oxford Provider is not necessary. Members with non-gated plans have "No Referral Required" printed on their Oxford ID cards. If the Member wishes to stay in-network, it is their responsibility to make certain the provider they are using is Participating with Oxford for their network (i.e., Liberty, Oxford Medicare Advantage).

  2. Non-Participating Oxford Providers
    A Non-Participating Oxford Provider is defined as not participating with Oxford Health Plans or not participating in the Oxford network available to an Oxford Member. For example, a provider may participate with Oxford's commercial Freedom network, but not the Oxford Medicare Advantage network. Therefore, this provider would be considered a Non Participating Oxford Provider for an Oxford Medicare Advantage Member.

    Members with out-of-network coverage may self-refer to Non-Participating Oxford Providers for medically necessary Covered Services and be eligible for coverage, subject to the plan's deductible and coinsurance and Precertification requirements, as well as out of pocket maximums (Member or Oxford).

  3. Exceptions to Referral Requirements (for those plans that require a Referral)

    This Type of Service Does not require a referral
    for...
    Visits to any Participating Oxford PCP or OB/GYN within the Member's network Oxford Medicare Advantage and Commercial Members
    Emergency care Refer to:Emergency Room Outpatient Services for Medicare Advantage and Emergency Room Visits Oxford Medicare Advantage and Commercial Members
    Urgent care Refer to:Urgent Care Services for Medicare Advantage and Urgent Care Oxford Medicare Advantage and Commercial Members
    Ambulance services in medical emergencies Refer to: Transportation Services Oxford Medicare Advantage and Commercial Members
    Mammograms Refer to: Screening Mammography/Diagnostic Mammography Oxford Medicare Advantage and Commercial Members.
    Pneumococcal vaccines administered in any setting, excluding the home but including Non-Participating Oxford Providers Refer to: Immunizations/Vaccinations for Commercial and Immunizations/Vaccinations for Oxford Medicare Advantage Oxford Medicare Advantage and Commercial Members.
    Influenza vaccines administered in any setting Refer to:Immunizations /Vaccinations for Commercial andImmunizations/Vaccinations for Oxford Medicare Advantage Oxford Medicare Advantage and Commercial Members
    Visits to any Participating Oxford radiology Provider or radiology facility within the Member's network. Oxford Medicare Advantage and Commercial Members
    Covering providers, as long as they identify themselves as covering on the claim or have the same FTIN Oxford Medicare Advantage and Commercial Members
    Certain diabetic supplies Refer to:Diabetes Supplies (including Blood Glucose Monitors, Insulin and Syringes) for Oxford Medicare Advantage and Diabetes Supply Coverage for Commercial Oxford Medicare Advantage Oxford Medicare Advantage and Commercial Members
    Blood transfusions Refer to: Transfusion/Blood Products Commercial Members
    Alternative medicine, if the alternative medicine benefit is present Refer to:Alternative Medicine Oxford Medicare Advantage and Commercial Members
    Laboratory and pathology services performed at a participating Quest network lab. A lab slip or Doctor's order can be used instead of a Referral. Oxford Medicare Advantage and Commercial Members
    DME under $500 and not custom molded, and certain medical supplies Refer to Durable Medical Equipment Commercial Members
    Post cataract glasses, including Non-Participating Oxford Providers Refer to:Intraocular Prosthetic Lenses/Post Cataract Glasses Oxford Medicare Advantage Members
    Enhanced Routine podiatry by a Participating Oxford Medicare Advantage Provider if the benefit is present Refer to: Routine Podiatry (Standard and Enhanced) for Medicare Advantage Oxford Medicare Advantage Members
    Standard hearing aid benefit provided by a Non-Participating Oxford Provider, not including hearing evaluation Refer to: Hearing Aids for Medicare Advantage Oxford Medicare Advantage
    Routine vision care services Refer to:Routine Vision Services for Medicare Advantage Oxford Medicare Advantage
    Out of Area hemodialysis Refer to: Dialysis Services Oxford Medicare Advantage
    One nutrition wellness visit (for those Oxford Medicare Advantage Members with the benefit) to a Participating Oxford Medicare Advantage registered dietitian every 12 months Refer to: Nutritional Wellness/Intervention for Medicare Advantage Oxford Medicare Advantage
    Oxford does not require a PCP Referral for services rendered by a Physician Extender who is employed by or works under supervision of the Member's PCP and/or OBGYN. Refer to: Physician Extenders Commercial Members and Oxford Medicare Advantage
    Commercial Members with Pennsylvania LOB's and New Jersey, New York or Connecticut Members who choose a Pennsylvania Primary Care Physician do not require Referrals. Commercial Members
    Delaware lines of business do not require a Referral. For Delaware Standard Indemnity plan and Basic Indemnity plan, deductible and coinsurance will apply. Commercial Members

References

  1. New York Physical Therapy Conflict of Interest Law. A3573, Chapter Law 591 (2000)

  2. Oxford Medicare Advantage Evidence of Coverage, 2005.

  3. Medicare Legal Review. June 24, 2003

# ADMINISTRATIVE 113.3 T0
Effective Date: January 1, 2005