Specialty Care & Services

Obtaining specialty care and services

 

When you have health care concerns, a good place to start is by contacting your PCP. Much of the time your PCP can provide the care that you need. Sometimes, however, you may need specialty care or services that your PCP does not provide.

For some services, your PCP is authorized to give you a referral to see a specialist (see PCP referral below) within the FCHP Direct Care network. If you receive services from any doctor, hospital or other health care provider outside of the FCHP Direct Care network without getting a prior authorization from FHLAC, you will have to pay for these services yourself.

Self-referral
In certain instances you can “self-refer” to a plan specialist. This means that you can call the specialist and make the appointment yourself. You do not need a referral from your PCP but you must see a plan provider.

Services you can self-refer for include:

  • Office visits with an FCHP Direct Care network obstetrician, gynecologist, certified nurse midwife or family practitioner, including annual preventive gynecological health examination and any subsequent gynecological services determined to be necessary as a result of such examination; services for acute or emergent gynecological conditions and maternity care. This does not include inpatient admissions or infertility treatment (unless provided by a Reliant Medical Group specialist and you have a Reliant Medical Group PCP).
  • Office visits with a Reliant Medical Group specialist (physician, physician assistant, nurse midwife or nurse practitioner only) if you have a Reliant Medical Group PCP
  • Office visits to an FCHP Direct Care network oral surgeon for the extraction of impacted teeth. (Visits to an oral surgeon for any other procedure require prior authorization from the plan.)
  • Outpatient mental health and substance abuse services with plan providers. For assistance in finding a network provider call: 1-888-421-8861 (TDD/TTY: 1-781-994-7660). Prior authorization is required after eight visits.
  • Visit to a contracted limited service clinic (appointments not required).

PCP referral
In some instances your PCP can refer you to a specialist without prior authorization from the plan. You are required to see a plan provider. Your PCP is responsible to ensure that the provider refers you to is within the FCHP Direct Care network. You do not need to do anything further and you will not get a letter from the plan.

Services that need a PCP referral but do not need prior authorization from the plan include:

  • If you have a Reliant Medical Group PCP, office visits with a plan specialist, with the exception of office visits with a Reliant Medical Group specialist.
  • Podiatric care. Your PCP will give you a prescription to an FCHP Direct Care network podiatrist. The referral is good for a maximum of one year, or until the condition is corrected, whichever comes first.
  • Chiropractic care. Your PCP will give you a referral to an FCHP Direct Care network chiropractor which may cover up to 20 visits, if medically necessary.
  • Physical and occupational therapy. Your PCP will give you a written order to take to an FCHP Direct Care network physical or occupational therapist. The written order covers medically necessary services up to your benefit maximum.

Prior authorization
For certain types of specialist visits and for certain specialty services, your PCP or specialist will need to obtain prior authorization from the plan before you receive services. Prior authorization is an assurance by the plan to pay for medically necessary covered services provided by a plan provider to an eligible plan member.

When a service requires prior authorization, your PCP or specialist will send a request for services to the plan. We will review the request and make an authorization decision within two business days of receipt of all the necessary information. For the purposes of this section, “necessary information” may include the results of any face-to-face clinical evaluation or second opinion that may be required.

We will inform your PCP of our decision within one business day. If FHLAC authorizes the service, FHLAC will send you and your PCP an authorization letter within one business day after the determination has been made. When you get the letter, you can call a plan specialist to make an appointment. The authorization letter will state the services the plan has approved for coverage.

Make sure that you have this prior authorization letter before any services requiring prior authorization are furnished to you.

If the specialist feels you need services beyond those authorized, the specialist will ask for prior authorization directly from the plan. If FHLAC approves the request for additional services, FHLAC will send both you and your PCP an authorization letter.

If FHLAC does not authorize a service, FHLAC will send you and your PCP a denial letter within one business day of the decision. The denial letter will explain the reasons for our decision and your right to file an appeal. For information on filing a grievance, see Inquiries, appeals and grievances.

Services requiring prior authorization from the plan include, but are not limited to:

  • Non-emergent admissions to a hospital or other inpatient facility
  • Some same-day surgery (outpatient) and ambulatory procedures
  • Services with a non-FCHP Direct Care network provider
  • Organ transplant evaluation and procedures
  • Reconstructive and restorative services
  • Infertility/assisted reproductive technology services
  • Oral surgery (with the exception of the extraction of impacted teeth)
  • Genetic testing
  • Neuropsychological testing
  • Prosthetics/orthotics and durable medical equipment
  • Hospice care
  • Non-emergency ambulance
  • High tech radiology, including, but not limited to, all outpatient MRI/MRA, CT/CTA, PET and nuclear cardiology imaging studies
  • Sleep study and/or sleep therapy
  • Oxygen
  • Outpatient mental health services (including intermediate care), beyond eight sessions
  • Speech therapy
  • Habilitative or rehabilitative care, including but not limited to ABA therapy
  • Therapeutic care
  • Injections and injectables that are included on the formulary, that are for covered medical benefits, and that are ordered, supplied and administered by a plan provider