Section 1374.16 Of Article 5. Standards From California Health And Safety Code >> Division 2. >> Chapter 2.2. >> Article 5.
1374.16
. (a) Every health care service plan, except a specialized
health care service plan, shall establish and implement a procedure
by which an enrollee may receive a standing referral to a specialist.
The procedure shall provide for a standing referral to a specialist
if the primary care physician determines in consultation with the
specialist, if any, and the plan medical director or his or her
designee, that an enrollee needs continuing care from a specialist.
The referral shall be made pursuant to a treatment plan approved by
the health care service plan in consultation with the primary care
physician, the specialist, and the enrollee, if a treatment plan is
deemed necessary to describe the course of the care. A treatment plan
may be deemed to be not necessary provided that a current standing
referral to a specialist is approved by the plan or its contracting
provider, medical group, or independent practice association. The
treatment plan may limit the number of visits to the specialist,
limit the period of time that the visits are authorized, or require
that the specialist provide the primary care physician with regular
reports on the health care provided to the enrollee.
(b) Every health care service plan, except a specialized health
care service plan, shall establish and implement a procedure by which
an enrollee with a condition or disease that requires specialized
medical care over a prolonged period of time and is life-threatening,
degenerative, or disabling may receive a referral to a specialist or
specialty care center that has expertise in treating the condition
or disease for the purpose of having the specialist coordinate the
enrollee's health care. The referral shall be made if the primary
care physician, in consultation with the specialist or specialty care
center if any, and the plan medical director or his or her designee
determines that this specialized medical care is medically necessary
for the enrollee. The referral shall be made pursuant to a treatment
plan approved by the health care service plan in consultation with
the primary care physician, specialist or specialty care center, and
enrollee, if a treatment plan is deemed necessary to describe the
course of care. A treatment plan may be deemed to be not necessary
provided that the appropriate referral to a specialist or specialty
care center is approved by the plan or its contracting provider,
medical group, or independent practice association. After the
referral is made, the specialist shall be authorized to provide
health care services that are within the specialist's area of
expertise and training to the enrollee in the same manner as the
enrollee's primary care physician, subject to the terms of the
treatment plan.
(c) The determinations described in subdivisions (a) and (b) shall
be made within three business days of the date the request for the
determination is made by the enrollee or the enrollee's primary care
physician and all appropriate medical records and other items of
information necessary to make the determination are provided. Once a
determination is made, the referral shall be made within four
business days of the date the proposed treatment plan, if any, is
submitted to the plan medical director or his or her designee.
(d) Subdivisions (a) and (b) do not require a health care service
plan to refer to a specialist who, or to a specialty care center
that, is not employed by or under contract with the health care
service plan to provide health care services to its enrollees, unless
there is no specialist within the plan network that is appropriate
to provide treatment to the enrollee, as determined by the primary
care physician in consultation with the plan medical director as
documented in the treatment plan developed pursuant to subdivision
(a) or (b).
(e) For the purposes of this section, "specialty care center"
means a center that is accredited or designated by an agency of the
state or federal government or by a voluntary national health
organization as having special expertise in treating the
life-threatening disease or condition or degenerative and disabling
disease or condition for which it is accredited or designated.
(f) As used in this section, a "standing referral" means a
referral by a primary care physician to a specialist for more than
one visit to the specialist, as indicated in the treatment plan, if
any, without the primary care physician having to provide a specific
referral for each visit.
(g) This section shall become operative on (1) January 1, 2004, or
(2) the date of adoption of an accreditation or designation by an
agency of the state or federal government or by a voluntary national
health organization of an HIV or AIDS specialist, whichever date is
earlier.