Physicians Choice Medical Group Authorization Process Changes – 7/1/15 Frequently Asked Questions General Information Q1.

How is the authorization request process changing? A. Physicians Choice Medical Group of San Luis Obispo (PCSLO) is modifying the way referral processing is conducted. With some exceptions, all authorization requests for specialist’s services should be routed through the member’s Primary Care Physician.

Q2.

Why is PCSLO changing the referral process? A. PCSLO has continued to see a decrease in PCPs managing and coordinating patient care. This will allow PCPs to manage and coordinate specialty care. Additionally, as Physicians Choice Medical Group of San Luis Obispo and Physicians Choice of Santa Maria move forward with their merger, day to day operations must be the same.

Q3.

When does this new process go into effect? A. The new process is effective July 1, 2015

Q4.

Does this new Authorization Process apply to the Marian Health Services (Dignity Health Central California/DHCC) medical plans? A. No. Referrals and authorizations for the patients in the DHCC EPO and EPO II plans are not affected by these changes.

Direct Referrals Q5.

Does this new process affect Direct Referrals by a PCP? A. Yes. Direct Referral forms to refer a patient to a specialist have been eliminated. All referrals to all specialists should be submitted through MCSOnline. In other words, no more faxing Direct Referrals to specialists.

Q6.

I am specialist who receives Direct Referrals from PCPs. What do I do if a PCP continues to forward Direct Referrals to me after 7/1/15? A. Inform the PCP office you no longer accept “Direct Referrals” and you will not be able to schedule the patient until an approved authorization is available on MCSOnline.

Q7.

As a specialist, will I have the ability to view authorizations on MCSOnline for patients referred to me? A. Yes. Approved authorizations are available to the PCP and the specialist to whom the patient is being referred via MCS online.

Specialists’ Services Q8.

I am a specialist whose patients require further services such as surgery or other inpatient or outpatient procedures after initial consultation. May I continue to submit to PCSLO my requests for authorizations? A. No. All subsequent treatment (surgery, procedures, diagnostic studies and followup visits) require authorizations submitted by the PCP. Requests for these services should be forwarded to the patient’s PCP for review. The PCP is responsible to submit all additional authorization requests.

Q9.

What is the process for a specialist to request ongoing or subsequent treatment such a surgery, procedures, or follow-up visits? A. Specialists should complete the PCP and Specialist Request for Services form located on MCSOnline. This form may be found in the Forms section under Provider Resources. Upon completion, fax the form and pertinent, supporting information to the patient’s PCP. The PCP will be responsible for reviewing the request and submitting the referral request for processing. Please provide supporting documentation with your request such as chart notes, lab/xray results. (Do not send multiple pages from your EMR which are not pertinent to request.)

Q10.

As a specialist who is asking to provide subsequent services, what if the PCP is not in agreement with my proposed treatment plan? A. It is up to the PCP to coordinate specialty care. Specialists and PCPs are encouraged to coordinate care plans. If the requested services fall within the PCP’s scope of care, the PCP will contact the patient and follow-up directly and notify the requesting provider.

Q11.

As a specialist who often requires patients to obtain additional diagnostic testing including MRIs or PET scans, will I be required to go through the PCP to request these services? A. Authorizations for diagnostic studies will not change. Plain films, U/S and CTs do not require authorization. For MRI, PET and any other diagnostic services which previously required authorization, please coordinate authorization request through the PCP. If the treatment plan request meets standards the PCP will submit an authorization request.

Q12.

If I am a specialist asking for services outside of my practice will I be able to view the authorization on MCSOnline and its status as I am not requesting the authorization myself? A. No. Please contact the PCP to discuss coordination of specialty care.

Q13.

What do I do as a specialist if the PCP does not review and submit my request timely? A. Please contact administration: Ms. Barbara Cheever at 805-903-1719 (effective 8/1/15 805-903-1700, ext. 6013). Please be prepared to provide specific details.

Primary Care Physicians Responsibilities Q14.

As a PCP, what are my responsibilities? A. PCP responsibilities were recently distributed to all PCPs. PCP scope of service includes managing specialty care. If you have questions regarding PCP responsibilities please contact Ms. Barbara Cheever at 805-903-1719 (effective 8/1/15 805-903-1700, ext. 6013).

Q15.

I’m a PCP who receives authorization requests from specialists. When am I expected to submit their requests to MCS? A. PCPs should review and submit authorization requests on behalf of the providers within 3 days of receiving the request from the specialist. Urgent request should be submitted within 24 hours. This should ensure patients with scheduled procedures or return visits are accommodated.

Q16.

As a PCP, how do I handle a request for an out-of-network provider? A. Requests for providers not in the PCSLO network should be re-directed back into the network unless the services are not available within the network. Request for services not available in network or by the preferred tertiary center should be submitted using the standard submission process.

Q17.

I’m a PCP who may determine a request from the specialist for a service is within my scope of care. How do I handle this? A. Contact the patient and follow-up with him/her directly. Notify the requesting specialists you will follow the patient and you will coordinate additional specialty services as needed.

Q18.

What if I receive a request that does not have enough information to support the request for additional services? Or, a request for a procedure or DME item without the needed CPT or HCPCS codes to submit the authorization request? A. Notify the requesting provider in writing that you are unable to submit the authorization requests without complete information. Request the provider to resubmit their request within 24 hours with complete information.

Exceptions Q19.

Are there exceptions to the rules? Is it possible to submit referral requests for some services or specialties? A. Yes. Selected specialties may submit requests directly to PCSLO. Please refer to current Referral Process Workflow.

Q20.

If I’m a capitated specialist, do the capitated services I provide require prior authorization? A. After the initial authorization request submitted by the PCP has been approved, capitated specialists (excluding Radiology and Lab), do not require additional authorizations for capitated services. Only non-capitated services require authorization. In addition, if you are performing a procedure/service in a facility (hospital/ASC) please submit an authorization request for the procedure and indicate the facility name and if the service will be done in an in-patient or outpatient setting. This will ensure the facility authorization is generated. (All services provided in a facility require authorization).

Help Q21.

If I have specific questions that are not addressed in this document or the memo dated 7/1/2015, who should I contact? A. Contact Provider Relations or Administration: 

Provider Relations Chris Galarza, Provider Relations Representative 805-903-1718 (effective 8/1/15 805-903-1700, ext. 6387) [email protected]



Administration Barbara Cheever, VP of Operations 805-903-1719 (effective 8/1/15 805-903-1700, ext. 6013) [email protected]

Physicians Choice of San Luis Obispo Referral Process Workflow July 1, 2015

Primary Care Physician Must generate all initial referrals via MCSO Following the initial referral the following providers may submit self referrals

Specialists California Retinal Consultants Central Coast Cardiothoracic Surgeons (Canvasser, Faber, Freyaldenhoven, Skow)

For additional services Specialists must send completed referral form to PCP for review and submission, including referrals to other specialties and radiology/diagnostics

Allowed to submit for additional services

Dialysis General Surgery (Associated Surgeons of SLO) Gynecology – Seniors only (Art Segal, MD) Hematology/Oncology Nephrology OB-GYN (ok to self-refer for WWE, Gyn & initial OB)

Ophthalmology Pain Management Pediatric Cardiology (Dr. Dale Rowland) Pulmonary Radiation Oncology Rheumatology Urology DME/Home Health/Ostomy Vendors

ADDITIONAL Services • Associated Surgeons can submit Pet Scans/MRI • Hem Onc can submit for Pet Scans/MRI, genetic testing, bone marrow bx • Radiation Oncology can submit for rad therapy, Pet Scans/MRI • Coastal Cardiology may submit referrals to CC Cardiothoracic Surgeons. All other referrals by Coastal Cardiology must go through PCP