To ensure that patient care is expedited, CMS managed IPAs adopt Direct Referral or Direct Access Programs that allow primary care physicians to refer members directly to specialists without the need to wait for an authorization. Most initial referrals, preventative health screenings and referrals for the treatment of urgent conditions are included under this program.
To expedite the review of requested services that may need clinical review, CMS offers the ability to submit requests electronically. To access this service, providers simply need to have access to the internet. Providers log on to our web site and submit the request on line. This system allows providers to track the status of these requests at any time during the day and minimizes the need for provider office staff to spend time on the phone. CMS also accepts hard copy referral requests through a centralized fax line. All requests received through this line are scanned to ensure that every request is reviewed and processed promptly. Once referral determinations are made, the member, requesting provider and rendering provider receive notice of the determination.
As a value added service, Referral Tracking reports are sent to each members PCP on a monthly basis. This report allows the PCP to ensure that all members obtain the services that they need. A similar report of members with critical conditions is sent to the appropriate specialists to ensure that they make arrangements to see the members quickly.
In addition, CMS offers access to a STAT desk that is staffed by administrative and clinical staff that assists physicians in coordinating urgent care quickly.
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