McLaren Health Plan
Referral Process Changes
Effective October 1, 2011 Select Outpatient Procedures No Longer Require Authorization
MHP is pleased to announce a pilot program that will decrease the administrative burden on our providers for services/procedures performed in the outpatient setting at an in-network facility.
Starting October 1, 2011, certain outpatient services/procedures, such as non- excisional scopes, a designated group of excisional scopes, and other identified outpatient procedures, will be reimbursed without an authorization when performed in the outpatient setting.
You can view a listing of all CPT codes* that do not require an authorization from the PCP or the hospital, when provided in the outpatient setting. This list is available under related links on the left hand side of this webpage, it is titled: Outpatient Procedures No Longer Requiring Authorization October 2011
* Any of these procedures when performed in the inpatient setting or at an out-of-network facility, still require an authorization/referral.
All services/procedures billed to MHP must be both, medically necessary and coded appropriately. MHP reviews paid claims to ensure compliance and accuracy.
For your convenience, there is also a list of CPT codes that require pre-authorization in the outpatient setting. This list is available under related links on the left hand side of this webpage, it is titled: Outpatient Procedures that REQUIRE Pre-Authorization October 2011
The Provider Referral Form has been revised to reflect these new changes. Please discard all old referral forms. Only use the new form dated July 2011.
MHP has made these changes in an effort to streamline processes for our participating practitioners and members. MHP remains committed to the Primary Care Physician as the gatekeeper and the medical home for our members. While the referral process has changed, ongoing coordination of care remains the Primary Care Physician's responsibility. MHP will continue to educate our members on the importance of discussing all health care needs with their Primary Care Physician.
Please contact MHP at (888) 327-0671 with any questions.