Prior Approval Process

 

Understanding the Referral Process

Q What is a referral request and when is it needed?
A A referral request is a form sent to Dean Health Plan, by your PCP, or specialty physician requesting permission for you to receive services from another provider outside of the Dean Health Plan network.

Your physician or DHP may limit the number of visits or type of service. Before receiving additional care, you must contact your referring physician for another referral request.

As a DHP member, it is your responsibility to obtain a valid referral request for out-of-network care. Please call a Customer Care Center specialist if you have any questions. Keep in mind - a referral request does not authorize payment of non-covered or exhausted benefits. Services are subject to all benefit maximums, policy limitations and eligibility requirements.

Q How do I get a referral request to a plan provider?
A In situations where your PCP recommends services that are not available at your primary clinic, he/she can refer your care to another provider within the DHP Provider Network. Your PCP will complete a Referral Request Form and send it to DHP for review. If the services are for a covered benefit, the referral will be processed as requested. You do not need to wait for confirmation from DHP before you go to your appointment or obtain services.

Q How do I get a referral request to a non-plan provider?
A In situations where your PCP recommends services with a provider who is not part of the DHP Provider Network, your PCP will complete the Referral Request Form and submit it to DHP for review. We will notify you of our decision by mail, and by phone if your request is urgent. If approved, you can then see the non-plan provider. If not approved, we will offer other options for treatment or providers.

Please note, only services that are not available with our plan providers are considered for approval for coverage with non-plan providers. You must wait to receive written notice that your request has been approved before seeing this provider. If you have not received written notice before your scheduled appointment, check with our Customer Care Center to avoid financial responsibility.

Q Are there services that do not require a referral?
A Written referrals are not required for the following types of services when provided by a Dean Health Plan Provider:

• Chiropractic Care
• Diagnostic Tests & Respiratory Therapy
• Durable Medical Equipment
• Home Health
• Hospice Care
• MRI (Magnetic Resonance Imaging)
• Services Provided by an OB/GYN
• Oral Surgery for Covered Procedures
• Routine Vision Care

Q If Dean Health Plan is my secondary insurance, do I still need a referral?
A Yes, in order for services to be covered, you must get a referral when necessary. This also applies to situations when another party may be liable for charges, such as workers' compensation or a liability insurance company in the case of an accident.

Prior Authorization

Some of our policies, such as Point of Enrollment, Point of Service, and Triple Option plans, do not require you to obtain any referrals. However, there may be certain services for which your plan requires pre-certification or prior authorization. It is important to know the difference between these two procedures. Your Member Certificate and Schedule of Benefits will outline which services require pre-certification or prior authorization. These documents will also indicate if your policy will apply a penalty for not receiving the required pre-certification or prior authorization. It is important that you follow these guidelines appropriately to receive the most benefits from your policy.

Prior Authorization is required for specific services or procedures. If your provider recommends that you have a service or procedure that requires prior authorization, the provider ordering or providing the service or procedure should submit a prior authorization request form to our Medical Affairs Division. It is the member's responsibility to be sure that prior authorization is obtained. The prior authorization request must be received by us at least 15 business days prior to the anticipated date of your service or procedure. Approval of an elective inpatient admission to a facility is required prior to the elective services being received.

Please note that a verbal request for prior authorization does not guarantee approval. Our Medical Affairs Division will notify you in writing of the decision regarding a determination for elective outpatient services.

Urgent or Emergency Care and Follow-Up Care

In the Service Area:		Outside of the Service Area:
Urgent Care Urgent care is care you need sooner than a routine doctor's visit. Some examples of urgent care are broken bones, sprains, minor cuts and burns, drug reactions, and nonsevere bleeding. Urgent care should always be received by a plan provider when you are in the service area.		Urgent Care Urgent care should be received at the nearest appropriate medical facility unless you can safely return to the service area. Please contact us by the next business day after seeing a non-plan provider. When we receive a claim for the services, it will be reviewed to determine if the diagnosis or symptoms were urgent. If so, payment will be based on our maximum allowable fee. You will be responsible for any fees that exceed this amount.
Emergency Care Emergency care is the sudden and unexpected onset of a medical condition that, if you did not seek immediate medical attention, could result in your death or serious injury to your body. Some examples of emergency care are heart attacks, strokes, severe shortness of breath, and significant blood loss. Note: If you have a medical emergency, please call 911 or proceed to the nearest medical facility. Most of the time, you will be able to receive emergency care from a plan provider. However, if you are unable to reach a plan provider, please go to the nearest medical facility for assistance. Please contact us as soon as possible if you must go to a non-plan provider.		Emergency Care If you are outside of the service area and require emergency care, please call 911 or go to the nearest medical facility. Please contact us by the next business day after receiving any emergency treatment or an emergency admission to a non-plan facility. If you are admitted to a non-plan facility for inpatient mental health services, we must be contacted within 72 hours of being admitted. Failure to contact us could result in your being financially liable for all services.
Follow-Up Care Follow-up care is care you receive after the initial urgent or emergency condition has been stabilized and you are discharged. Follow-up care in the service area must be received from plan providers.		Follow-Up Care Follow-up care for an emergency or urgent care condition by a non-plan provider must be prior authorized. Please contact our Customer Care Center before receiving any follow-up care out of the service area.

Dean On Call

Dean On Call is a 24-hour nurse line that is staffed with nurses who are trained to assess your health care issues. They can help you in determining the type of care that will be best for you or your family members. They can also help you decide whether symptomatic treatment is needed instead of a trip to the emergency room, or advise you where to go for further health care. The nurse can also tell you what type of follow-up care is needed.

Note: If you have a medical emergency, please call 911 or proceed to the nearest medical facility.

To use Dean On Call, just call toll free 1-800-57-NURSE (1-800-576-8773), day or night, to get the help you need when you need it. If you are in the Madison area, please call (608) 250-1393.

*Due to licensing regulations, Dean On Call's triage services are only available to residents of Wisconsin.