10.2.36 Standing Referral - Extended Access to Specialty Care Form

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Policy Title: Standing Referral/Extended Access to Specialty Care POLICY #: 10.02.36 Line of business: Medi-Cal Department Name: Utilization Management Original Date: 1/99 Effective Date: 5/19 Revision Date:
Governing Committee: (If Applicable)

VP Approval: Tracy Alvarez, VP, Medical Care Solution

Date of Approval: 3/11/2025 Medical Services/P&T Committee: (If Applicable) Jennifer Nuovo, MD, Blue Shield Promise Chief Medical Officer Date of Committee Review: 3/11/2025

A. PURPOSE To provide guidance on how Blue Shield of California Promise Health Plan’s (Blue Shield Promise) Utilization Management (UM) Department will authorize a standing referral.

B. DEFINITIONS

1. HIV/AIDS Specialist – means a physician who holds a valid, unrevoked and unsuspended certificate to practice medicine in the State of California who meets any one of the following four (4) criteria: a. Credentialed as an HIV Specialist b. Board certified, or has earned a Certificate of Added Qualification in the

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field of HIV medicine c. Board certified in the field of infectious diseases d. Meets the qualifications stated in 28 California Code of Regulations (CCR) § 1300.74.16(e) and (f).

2. Specialty Care Center – means a center that is accredited or designated by an agency of the state or federal government or by a voluntary national health organization as having special expertise in treating the life-threatening disease or condition or degenerative and disabling disease or condition for which it is accredited or assigned.

3. Standing Referral – means a referral by a primary care physician to a specialist for more than one visit to the specialist, as indicated in the treatment plan, if any, without the primary care physician having to provide a specific referral for each visit. C. POLICY

   I. Blue Shield Promise does not require prior authorization with in-network providers for standing referrals. When an out of network (OON) request is submitted, Blue Shield Promise shall provide for a standing referral to a specialist if the primary care physician (PCP) in consultation with the specialist, if any, and Blue Shield Promise's Medical Director or designee, determines that a member needs continuing care for his/her chronic, disabling condition in accordance with Health & Safety Code §1374.16(a)

   II. A member with a condition or disease that requires specialized medical care over a prolonged period of time and is life-threatening, degenerative, or disabling may receive a referral to an OON specialist or specialty care center that has expertise in treating the condition or disease for the purpose of having the specialist coordinate the member’s health care in accordance with Health & Safety Code §1374.16(b).

   III. OON standing referrals will be made pursuant to a treatment plan approved by Blue Shield Promise in consultation with the PCP, the specialist, and the member, if a treatment plan is deemed necessary to describe the course of the care. a. A treatment plan may be deemed to be not necessary provided that a current standing referral to a specialist is approved by Blue Shield Promise or its contracting provider, medical group, or IPA. The treatment plan may limit the number of visits to the specialist, limit the period of time that the visits are authorized, or require that the specialist provide the PCP with regular reports on the health care provided to the enrollee. b. Referrals will be made to those specialty providers that have demonstrated expertise in treating the condition and the treatment of the condition has been deemed to be medically necessary by Blue Shield Promise.

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c. A request for an OON standing referral to a specialist may be initiated by the member, the PCP, or the specialist, when the member has a disabling, life threatening or degenerative condition, including HIV and AIDS, or any condition or disease that requires specialized medical care over a prolonged period of

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time.

D. PROCEDURE When Blue Shield Promise receives an OON request, the request will be authorized, modified, or denied in accordance with Health & Safety Code §1363.5 and §1367.01. I. Requesting a Standing Referral: a. When authorizing a standing referral to a specialist for the treatment of a disabling, life threatening, or degenerative condition, the following will occur: i. The request will be made by the member’s PCP, specialist or the member. ii. The referral request will be made to a Blue Shield Promise contracted specialist, HIV/AIDS specialist, or specialty care center unless there is no specialist within the plan network that is appropriate to provide treatment to the member. iii. If no specialist qualified to treat the disabling condition is available in the network, then the referral will be made to a non-contracted provider, as outlined in 10.02.41 Out of Network Services. b. Standing referral requests will include: i. Diagnosis ii. Required treatment plan iii. Requested frequency and time period iv. Relevant medical records

II. Decision Timeframes: a. The determination will be made within three (3) business days of the date the request for the determination is made by the member or the member’s PCP and all appropriate medical records and other items of information necessary to make the determination are provided. b. Once a determination is made, the referral will be made within four (4) business days of the date the proposed treatment plan, if any, is submitted to the plan medical director or his or her designee. c. Services will be authorized as medically necessary for proposed treatment, of a duration not to exceed one year at a time, utilizing established criteria and consistent with benefit coverage. d. After the referral is made, the specialist will be authorized to provide health care services that are within the specialist’s area of expertise and training to the member in the same manner as the member’s primary care physician, subject to the terms of the treatment plan.

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e. The approval will include: i. Number of visits approved ii. Time period for which the approval will be made iii. Clause specifying: “patient eligibility to be determined at the time services are provided” f. Denials, deferrals, or modifications of standing referrals are processed in accordance with 10.02.08 Authorization Denial, Pending/Deferral, and/or Modification Notification.

E. MONITORING N/A

F. REPORTING N/A

G. Attachments

1. 10.02.08 Authorization Denial, Pending/Deferral, and/or Modification Notification
2. 10.02.41 Out of Network Services

3. PHP UM Program Description

   H. REFERENCES

4. 28 CCR §1300.74.16(e) and (f)
5. Department of Managed Health Care, 2015 Technical Assistance Guide, Requirement UM-011: Standing Referrals
6. CA Health and Safety Code, §1374.16 (a-f)

7. LA Care Health Plan, Audit Tool, 2013

   I. REVISION HISTORY

   Date Modification (Reviewed and/or revised) E-Filing Number 3/2025 2025 Annual Review
   • Reviewed regulatory requirements per DHCS, NCQA • Minor formatting updates 3/2024 2024 Annual Review • Reviewed regulatory requirements per DHCS • Minor grammatical/formatting updates • Added denial/modification content • Updated references 2/2023 Updated Regulatory Requirements DHCS