Providers

• Training
  • Schedule an Orientation in Your Office
• Resources
  • Interpretation Services
  • Member Rights and Responsibilities
  • NaviNet
  • PCP Auto Assignment
  • Prior Authorization
  • Provider Claims Update
  • Provider Directory
  • Provider Forms
  • Provider Grievances
  • Provider Handbook
  • Provider Marketing Guidelines
  • Provider Reference Guide
  • Referrals
• Billing
  • Billing Manual
  • Durable Medical Equipment Fee Schedule
  • Electronic Funds Transfer
  • Electronic Claims Submission (EDI)
  • Electronic Remittance Advice (ERA)
• Non-Contracted Providers
  • Continuity of Care for Non-participating Providers
  • Contracting Information
  • Non-Participating Provider Demographic Information Form
  • Prior Authorizations
• Communications
  • Contact Account Executive
  • DHH Information
  • LaCare Provider Letters

Referrals Process

When a PCP determines the need for medical services or treatment, which occur outside the office, he/she must approve and/or arrange referrals to a participating Specialist. Referrals are valid for 180 days with unlimited visits.

The PCP should follow the steps outlined below prior to advising the member to access services outside of the office.

The PCP's office should:

• Verify member eligibility
• Determine if the needed service requires a referral or Prior Authorization from LaCare (See "Services Requiring Referrals and Prior Authorization" in the Provider Handbook).
• Select a participating Specialist appropriate for the member's medical needs from the Specialist Directory, as appropriate. (If an appropriate network provider is not listed in the network provider Directory please call Provider Services 888-922-0007 for assistance. See "Out-of-Plan Referrals" in this Section for additional information.)
• Specialists must follow the following appointment standards
  • Emergency appointments immediately upon referral
  • Urgent Care appointments within twenty-four (24) hours of referral
  • Routine appointments within one month of the referral

Paper Referrals

• Issue a pre-numbered referral form for procedures requiring referrals.
• When issuing a referral form, make sure the form is legible and that all the required fields are completed. See the sample referral form in Appendix 6.
• The date of service must not be prior to the date the referral was requested.
• Mail yellow referral copies to:

LaCare Health Plan
Claims Processing Department
PO Box 7322
London, KY 40742