Non-designated provider referrals for the Restricted Recipient Program
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This policy governs referrals and reimbursement for non-designated providers when members in the Restricted Recipient Program seek care; it affects providers treating members on the Restricted Recipient Program.
Referrals to a non-designated provider received more than 90 days from the date of service will not be reimbursed.
Coverage and Reimbursement Criteria
Non-designated provider referral reimbursement rules
Coverage and reimbursement criteria for non-designated provider services:
Coding and Key Values
| No codes listed |
Provider Actions and Claim Handling
Authorization for timely referrals
If the designated (restricted recipient) provider submits a referral less than 90 days from the date of service, Hennepin Health will enter an authorization in the care management system and the non-designated provider claim will be paid.
Late referrals will not be reimbursed
Referrals received more than 90 days from the date of service will not be reimbursed; no approval or denial is entered for these late referrals, but the referral is documented in the member's case and calls are made to the designated and non-designated providers informing them the service will not be paid.
Claim denial and reprocessing when referral arrives after claim
If a claim is received before the designated provider referral is submitted, the claim will be denied and a DTR issued; once the designated provider referral is received and an authorization entered (if within 90 days of the date of service), the claim will be reprocessed and paid.
Definitions
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