Follow-up care with a specialist

The specialist's office may need to contact our Review Services Department to obtain prior authorization for the situations listed below.

Click here for exceptions to our prior authorization requirements

Emergency room

If a specialist provides consultation for a member in an emergency room (in person), regardless of the provider's contract status, the specialist may be able to see that member for appropriate follow-up care with prior authorization, if necessary.

Request for authorization of follow-up care will be reviewed on an individual basis to determine medical necessity.

An emergency room specialist may refer a patient directly to an ophthalmologist or optometrist for care, regardless of the specialist's contract status. The scope and length of that authorization will be determined by a clinical review of the request.

Inpatient care

Contracted specialty physicians in a member's network who have consulted on a patient during an inpatient stay are allowed appropriate follow-up care with the patient in accordance with our authorization guidelines, provided that care begins within 30 days of the hospital discharge.

Non-contracted or non-network physicians who have consulted with a patient during an inpatient stay can see the patient for consultative follow-up care — for the purpose of transitioning care to a network provider — provided that care begins within 30 days of the hospital discharge.

The patient's primary care provider or contracted specialist may need to submit a request to authorize any additional visits to both contracted and non-contracted specialists.

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