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With the exception of care for Emergency Conditions, In-Plan services must be approved by your participating Primary Care Provider and provided by a Participating Provider. Under the following circumstances, however, upon referral, you may see a specialist or provider that is not in the AHP network or receive ongoing specialty care from non-participating providers. This care will be provided at no additional cost to you beyond what you would otherwise pay for services received within the network.
• If the Plan does not have a health care provider with appropriate training and experience in the network to meet the particular needs of a Member, a referral will be given to an appropriate provider outside the network.
• If the Plan deems it necessary to use providers outside the Network and approves such care in writing.
• If a member has been given a positive or negative diagnosis of cancer or a recommendation of a course of treatment for cancer, the Plan will approve coverage for a second medical opinion from a non-participating specialist, including but not limited to a specialist affiliated with a specialty care center for the treatment of cancer.
• If a member has a life threatening condition or disease or degenerative and disabling condition or disease which requires prolonged specialized medical care, the Plan may approve a referral to a specialist to provide and coordinate the Member’s primary and specialist care. The Plan may limit the number of visits or period of authorization and require the specialist to provide information to the Member’s Primary Care Provider.
• If a member has a life threatening condition or disease or degenerative and disabling condition or disease, which requires prolonged specialized medical care, the Plan may approve a referral to a designated or accredited specialty care center. The Plan does not cover travel expenses associated with referrals to specialty care centers even if significant travel is required unless travel is included in the rate of payment negotiated with the specialty care center.
Evaluation of the Member’s condition will be discussed between the AHP Medical Director and requesting provider to determine if such a referral is appropriate. The referral will be provided pursuant to a treatment plan that has been approved by the AHP Medical Director.
You, your PCP, AHP Specialist or out of network provider may call the AHP Utilization Department and request a standing referral to an Out of Network Specialist and/or Specialty Care Center.
If a member’s health care provider leaves the Plan’s network for reasons unrelated to quality of patient care, question of imminent harm to patients, fraud, or disciplinary action, the Plan will allow the Member to continue an ongoing course of treatment with the provider for a transition period of up to 90 days from the date of notice to the member of the provider’s disaffiliation from the AHP network. In the case of a pregnancy that has entered the second trimester at the time of the provider’s disaffiliation, the transitional period will include the provision of postpartum care directly related to the delivery.
The Plan will allow a new member to continue an ongoing course of treatment with an existing provider if the Member has a life threatening condition or disease or degenerative and disabling condition or disease for a transitional period of up to sixty (60) days from the effective date of enrollment. In the case of a Member who has entered the second trimester of pregnancy at the time of enrollment, the transitional period will include the provision of post-partum care directly related to the delivery.
Transitional care will only be authorized if the health care provider agrees (1) to accept AHP’s reimbursement rates as payment in full; (2) to adhere to AHP’s quality assurance requirements and to provide the necessary medical information related to such care; and (3) to otherwise adhere to AHP policies and procedures including, but not limited to procedures regarding referrals and obtaining pre-authorization and a treatment plan approved by AHP.