提供者手册

转介程序

Carelon will ensure that referrals to providers and between providers are coordinated with the goals of maintaining continuity of care and the clear communication of salient clinical information.

Referrals Made by Carelon to Providers

The goal of Carelon in making referrals to providers is to ensure that members receive access to service in a timely manner, according to their clinical needs.

When calls from members come into the Carelon Engagement Center, a Service Manager assesses the member’s needs in order to triage the call into an emergency, urgent, or routine level of acuity.

其需求被评估为紧急性质的成员会立即被转介到最近的最能满足其临床需求的机构或机构。

Members whose need for treatment is urgent or routine are referred for further evaluation with a local provider who can meet the HealthChoices access requirements. (These standards require that emergencies have face-to-face contact with a provider within 60 minutes, urgent referrals within 24 hours, and routine referrals within seven days.) Following the requirements of the Commonwealth, the member must always be offered the choice of at least two providers, as long as the providers can meet the member’s language and cultural needs. The Carelon provider database allows our Service Managers/CAFS Coordinators to ascertain the providers within the member access requirements.

Each member has the right to request a second opinion from a provider within the network at no cost to the member. If necessary, Carelon may arrange for a second opinion with a provider outside of the network.

提供者之间的推荐

如果会员需要从一个提供者转移到另一个提供者或从一个护理级别转移到另一个护理级别，转介提供者应遵守以下程序（紧急情况除外）：

  1. 转诊/转诊至所有级别的护理（门诊除外）
    转介提供者应联系免费提供者号码，并按照本手册第 III 部分中的说明进行预授权过程。
  2. 转诊/转诊至门诊护理水平
    遵循本手册第 III 部分所述的门诊护理程序。

Referrals Made by Carelon to Out-of-Network Providers

Carelon does not encourage making referrals to out-of-network providers. However, the following circumstances exist where this need may arise:

  • 要求提供仅由网络外提供者提供的独特或专业服务（例如，性虐待、PTSD）
  • 请求的服务在城市（30 分钟）或农村（60 分钟）访问标准范围内不可用，并且已批准例外（豁免）。
  • 成员在区域外并需要紧急护理或需要立即获得短期治疗
  • 提供者当前正在经历成为网络内提供者的过程，并且成员请求被该提供者看到

所有网络外转诊必须得到临床经理和/或临床主任的批准。