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Hennepin Health-PMAP and Hennepin Health-MNCareOut-of-Network Referrals vs. Authorizations FAQHennepin Health has an Accountable Care Organization (ACO) partnership with Hennepin Healthcare (formerly known as HCMC), NorthPoint Health & Wellness Center, and Hennepin County Health and Human Services. Hennepin Healthcare clinics and HCMC hospital, and NorthPoint Health & Wellness Center (ACO partner providers) make up the ACO defined partnership network. In addition to the ACO defined partnership network, Hennepin Health’s network includes North Memorial clinics, Community University Health Center (CUHCC), Cedar Riverside People’s Center, The Freemont Clinic, The Indian Health Board and more (in-network non-ACO partner providers). A complete list of clinics can be found on Hennepin Health’s website.The referral requirements for accessing out-of-network providers differ between the ACO defined partnership network and in-network non-ACO partner providers. This FAQ document provides tips and answers common questions. The referral and authorization rules do not apply to state and federally mandated family-planning services, termed open access/free choice, or for emergency, urgent or post-stabilization care. Additionally, Hennepin Health does not require members to obtain behavioral health, mental health, substance use disorder, acupuncture or chiropractic care from a defined network other than from providers enrolled and in good standing with Minnesota Medicaid. Please note: The Restricted Recipient Program may have additional rules and requirements. Click here for information on the Restricted Recipient Program from the Department of Human Service’s website.FAQsQ: What is the difference between a referral and request for authorization? A: A referral is a written order from a primary care provider for a member to see a specialist or receive certain health care services. A request for authorization is defined as a request to Hennepin Health (the health plan) to render a decision to determine if a health care service, a treatment plan, a prescription drug or durable medical equipment (DME) is medically necessary. This process may also be referred to as a prior authorization, prior approval or precertification. Hennepin Health requires an authorization for certain services before the member receives them, except in an emergency. Q: Does Hennepin Health require members to obtain referrals to see specialists within the Hennepin Health network? A: No referrals are required for members to access care provided by Hennepin Health network providers. This is also termed “direct access.” Q: What if there is not a provider within the Hennepin Health network that meets the member’s care needs, but there is a clinic outside the Hennepin Health network that can? A: If there is not a provider within the Hennepin Health network available or able to meet the member’s care needs, a Hennepin Health partner provider may refer a member to an out-of-network provider and an in-network non-ACO partner provider may request an authorization (see table below). Q: An ACO partner provider referred a member for an evaluation for a potential surgery. Surgery is recommended for the member; is there any more the surgery office should do? A: Yes, a referral is not the same as an authorization request. The referral tells Hennepin Health that the primary care provider is aware and has arranged for the member to seek consultation or treatment out of network. The referral alone does not constitute a decision by Hennepin Health that the resulting treatment plan, health care service, prescription drug or other medical service meets the coverage criteria and medical necessity requirements. The surgery or procedure proposed by the out-of-network provider/surgeon may be a service that requires a clinical review by Hennepin Health. Regardless, a request for authorization must be submitted to Hennepin Health by the out-of-network specialist provider/surgeon, and will need to be reviewed and authorized by Hennepin Health. In some cases, a determination will be made as to whether the services requested are medically necessary. The following grid will help simplify the authorization request/referral process for out-of-network providers. REFERRING PROVIDEROUT-OF-NETWORK PROVIDER PROCESS Hennepin Health ACO partner providers (Hennepin Healthcare clinics and HCMC hospital, and NorthPoint Health & Wellness) Referral notification required:Complete the Hennepin Health Partnered Provider Out-of-Network Referral FormHennepin Health in-network non-ACO partner providers Authorization request required:Complete the Hennepin Health Service Authorization FormThe above forms can be found on Hennepin Health’s website. Completed forms can be submitted to Hennepin Health by fax to the attention of Hennepin Health’s Medical Administration Department at 612-677-6222 (preferred) or mail at: Hennepin HealthAttention: Medical Administration Department400 South Fourth Street, Suite 201 Minneapolis, MN 55415 From the date/time an authorization request is received by Hennepin Health, the turn-around time is as follows: Standard requests: 10 business daysUrgent requests: 72 hours ................
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