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Specialist Referral Process

The Preferred Specialist Network

Using high-level data analytics, HCP has identified more than 5,000 specialty care providers across all non-hospital specialties to serve as the core of our referral network, the HCP Preferred Specialist Network.

These high-quality providers work with our PCPs to offer excellent care with a preference to providing care outside of the hospital setting whenever possible.

“Centers of Excellence” Provider Practices

An elite subset of the PSN, our Centers of Excellence provider practices offer the highest level of collaboration and service to our providers and members.

Referral Process to PSN/COE specialists

Referral to a PSN specialists is done with ease; no referrals or authorizations are needed for PCP-to- PSN specialist referrals, nor for PSN specialist-to-PSN specialist referrals. You can have your patients see any one of these PSN/COE specialists, for as many visits as are required to keep your patients stable and in good health.

To ensure you are referring to a PSN specialist, use the Find an HCP Preferred Specialist tool to locate a provider by specialty, geography and/or name.

By having your patients see providers in the Preferred Specialist Network you are giving them the best opportunity to remain healthy and stable without the added unnecessary cost of hospital-based services.

Referral to a PSN specialist is done with ease; no referrals or authorizations are needed for PCP-to- PSN specialist referrals, nor for PSN specialist-to-PSN specialist referrals.

Exception: Referral Process for EmblemHealth Cohort 2 Members

The PSN can provide care to all HCP Direct patients with EmblemHealth and Empire Medicare with No Referral Necessary, however when referring EmblemHealth Cohort 2 patients, a NOTIFICATION to HCP by the PCP is required for every visit in order to ensure accurate payment to the specialist.

NOTIFICATION Process for EmblemHealth Cohort 2 members

There are several ways to process a Notification to HCP to alert us that an EmblemHealth Cohort 2 member is being referred to a PSN Specialist:

Preferred Method of NOTIFICATION

Enter a Prior Authorization request into EZ-Net for E&M code 99213 for the Specialist/member visit. This documents the encounter in the claims system to ensure payment for whatever E&M code is submitted on the specialist’s claims.

Important Note: The use of code 99213 has no impact on specialist reimbursement, because this triggers NOTIFICATION and not a Prior Authorization.

Alternative Methods of NOTIFICATION

    1. Fax a Prior Authorization Request to 1(888) 746-6433 using the same approach as above 
    2. Call our Customer Engagement Center 866-685-8996 to provide the details of the referral, providing all of the following information:
      • Member Name
      • Member ID number
      • Specialist name
      • Specialty
      • Specialist address
      • Expected date of visit

Remember the NOTIFICATION process only applies to EH Cohort 2 members.

In the rare situation that you are unable to find the outpatient care you need within the HCP PSN, a referral to a NON-PSN provider will require a Prior Authorization to be submitted to HCP by the PCP.