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Referrals and Authorizations FAQ
- What is the difference between a referral request and an authorization request?
- What does the eligibility disclaimer mean?
- What is the direct line for authorizations and referrals?
- What is referral scope?
- What is a surgical option?
- Do members need a referral for routine vision services, annual women's exam, or maternity care?
- If the OB/GYN finds something during a routine exam that requires additional testing or treatment, can he/she request an authorization without going through the Primary Care Physician (PCP)?
- Do diagnostic procedures, including CAT scans, MRIs or special x-rays need a referral?
- How do I extend a referral?
- What is the ODS ON CALL/CALL-SHARE POLICY with regard to referrals?
- If a procedure or service is excluded from the member's plan benefits, can we obtain authorization if we are able to establish medical necessity?
- Are referrals or authorizations required for mental health / chemical dependency treatment?
What is the difference between a referral request and an authorization request?
A referral request is a request by a primary care physician (PCP) for ODS approval for a patient to see a specialist. An authorization request is a request for approval of a service for a member based on review of the member's plan benefits and/or review of the service for medical necessity.
What does the eligibility disclaimer mean? "If your plan is "fully insured", as described in your Member Handbook, eligibility is binding for 5 business days and quoted benefits are binding for 30 business days from the date of authorization. For all plans, services are subject to eligibility and plan provisions, including pre-existing condition limitations, in effect at the time services are rendered."
ODS will guarantee member eligibility for five business days following the date the authorization is approved. Eligibility must be in effect for services performed after this five-day period. ODS also guarantees benefits for 30 days from the date the authorization is approved. Services after this 30-day period are subject to benefits that are in place at the time the services are rendered.
What is the direct line for authorizations and referrals?
ODS has dedicated telephone lines for healthcare professionals who wish to process requests for referrals and/or service authorizations. Please call 503-243-4496, locally, or at 1-800-258-2037 if you are calling long distance.
What is referral scope?
Referral scope indicates what is included in the approved referral request, e.g. number of visits, outpatient diagnostic tests, office treatment.
What is a surgical option?
Surgical option is permission given by the PCP and ODS, that allows the specialist to request authorization for certain diagnostic procedures or treatment directly, without having to first report findings back to the PCP. It is not an approval for these services. Please refer to the focus list for services requiring authorization.
Do members need a referral for routine vision services, annual women's exam, or maternity care?
No, they can self refer to a participating optometrist for vision services or to a participating OB/GYN for routine annual women's exam and/or maternity care. Benefits may be limited for these services. Contact customer service for benefit limitations and exclusions.
If the OB/GYN finds something during a routine exam that requires additional testing or treatment, can he/she request an authorization without going through the Primary Care Physician (PCP)?
Yes, if an OB/GYN determines that further medical investigation is needed relating to an OB/GYN condition, he/she may contact ODS without going through the PCP for an authorization. Nevertheless, the PCP should be informed of the gynecologic condition discovered during the exam. If the medical condition is not related to OB/GYN, then the PCP will have to initiate any follow-up referrals or authorizations. Some groups have exceptions, refer to the ODS referral guidelines.
Do diagnostic procedures, including CAT scans, MRIs or special x-rays need a referral?
Normally, they do not need a separate referral authorization as long as the PCP, or a specialist to whom we have an authorized referral, orders the diagnostic tests. There are some diagnostic tests that do require an authorization, such as Bone Mineral Density Studies. For a list of diagnostic procedures requiring authorization, refer to the ODS referral guidelines. Use of non-contracted providers may result in lower benefits or in some cases no benefits at all.
How do I extend a referral?
To extend the dates or increase the number of visits on an expired referral, the patient's current primary care physician needs to submit the referral extension request to ODS contact the medical intake unit.
What is the ODS ON CALL/CALL-SHARE POLICY with regard to referrals?
ODS will honor the existing specialist referral without going back through the PCP for on call and call-share situations. The referral will be valid for the specialist's call-share partner(s). Situations in which this may occur are if the "referred-to" specialist is out of the office due to illness or vacation, is unavailable due to patient load, or if the "referred-to" specialist feels one of the call-share partner(s) is better suited to handle the patient's problem.
NOTE: Call-share specialists must be in network with the patient's plan for the patient to receive the higher level of benefits.
If a procedure or service is excluded from the member's plan benefits, can we obtain authorization if we are able to establish medical necessity?
If a procedure or service is excluded from the member's plan, benefits will not be available even if medical necessity is established. Please refer to the member's plan benefits for limitations and exclusions.
Are referrals or authorizations required for mental health / chemical dependency treatment?
Referrals are not required for mental health/chemical dependency treatment. Certain plans do require authorization for treatment. Please contact the customer service to determine if authorization is required, and to obtain benefit limitations and exclusions.