(A) A health insuring corporation that does not allow direct access to all specialists shall establish and implement a procedure by which an enrollee may receive a standing referral to a specialist. The procedure shall provide for a standing referral to a specialist if a primary care provider determines in consultation with a specialist that an enrollee needs continuing care from a specialist. The referral shall be made pursuant to a treatment plan approved by the health insuring corporation in consultation with the primary care provider, a specialist, and the enrollee. 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 primary care provider with regular reports on the health care provided to the enrollee.
(B) A health insuring corporation shall establish and implement a procedure by which an enrollee 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 a specialist who has expertise in treating the condition or disease for the purpose of having the specialist coordinate the enrollee's health care. The procedure shall provide for such a referral if a primary care provider determines in consultation with the specialist that the enrollee needs the specialist's expertise. The referral shall be made pursuant to a treatment plan approved by the health insuring corporation in consultation with the primary care provider, the specialist, and the enrollee. After the referral is made, the specialist is authorized to provide health care services to the enrollee in the same manner as the enrollee's primary care provider, subject to the terms of the treatment plan.
(C) The determinations described in divisions (A) and (B) of this section shall be made within three business days after a request for the determination is made by the enrollee or the enrollee's primary care provider and all appropriate medical records and other items of information necessary to make the determination have been provided.
(D) Once a determination in favor of a referral is made, the referral shall be made within four business days after the determination. This time period does not apply to standing referrals involving a rare or unusual condition for which appropriate specialists are limited in number or otherwise difficult to identify.
Divisions (A) and (B) of this section do not require a health insuring corporation to permit an enrollee to elect referral to a specialist who is not employed by or under contract with the health insuring corporation for the provision of health care services to the health insuring corporation's enrollees.
Effective Date: 10-01-1998