As a member of GHC-SCW, you have access to the outstanding care and services provided by GHC-SCW Providers at our primary care clinics. At times, your Primary Care Provider (PCP) may recommend a Specialist outside of the GHC-SCW owned and operated primary care clinics to best address your health.
Accessing Specialty Care
When you see your PCP, he or she may need a Specialist opinion. Planned specialty office visits outside of GHC-SCW Primary Care Clinic networks require coordination by your PCP. Members must receive an approval letter from the GHC-SCW Care Management department before receiving these services. You do not need prior authorization from GHC-SCW, or from any other person (including a PCP), in order to obtain access to obstetrical or gynecological care from a health care professional in your selected network who specializes in obstetrics or gynecology.
The referral request occurs when you visit your PCP and a decision is made to send you to a specific Specialist. An order is placed in your electronic medical record (EMR) which sends a message to the Care Management department. Many of the referral decisions can be viewed in the EMR while you are still in the office. For any referral request that must be reviewed, a team of experienced Care Management staff will evaluate the order. They will determine if the order is a covered benefit, and review it against national care guidelines for determination if care is medically necessary. Most referral decisions occur within 48 hours. Up to 15 days are allowed for review by the Care Management team and/or the Medical Director.
When the Care Management department approves the referral request, a letter is mailed to you and the Specialist. When you receive your approval letter, you may schedule the appointment to see the specialist. It is also helpful for you to take your approval letter to your appointment as it is not always seen in the specialty electronic medical record. If you make an appointment without approval from GHC-SCW Care Management, you may be responsible for full payment of the services provided.
If your referral request is denied, you will receive a denial letter in the mail explaining your member appeal rights. If your appointment has already been scheduled for the same day or next day after the denial decision is made, you will receive a call from the GHC-SCW Care Management department to notify you of the denial decision. GHC-SCW approves services or supplies based on the information that is available at the time of the approval/denial decision. Approval does not guarantee a member’s eligibility or benefits under his/her health plan. It is the responsibility of the member to know their deductible, Co-pay or Co-insurance amounts that apply to specialty services.