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Role of the Specialist Physician

If a PCP decides that a member requires care from a specialist, the PCP will refer the member to a participating HealthPlus specialist, through the appropriate HealthPlus referral process.

 The specialist will:

  • understand the reimbursement for his or her professional services rendered to HealthPlus members will be based upon the HealthPlus fee-for-service or Medicare fee schedule.
  • look to HealthPlus for compensation for services rendered to a member when such services are covered by HealthPlus’ subscriber contract.
  • agree not to bill, charge, collect a deposit from, seek compensation from, seek remuneration from, surcharge, or have any recourse against an enrollee except to the extent that copays are specified in an HealthPlus subscriber contract, or as permitted under the principles of coordination of benefits for covered benefits.
  • use his or her best efforts to bill within 60 days, but in all events to submit to HealthPlus, all claims for covered services, within one year of the date of service or hospital inpatient discharge.
  • participate in, and fully cooperate with, HealthPlus’ utilization review, peer review and quality assurance programs, including by way of example and not by way of limitation, pre-admission certification, emergency admission certification and extension of hospital stays.
  • provide written reports to the referring primary care physician, to include his or her clinical findings and conclusions, in a timely manner, which will not be later than 30 days from date of service.
  • utilize providers who are contracted with or through HealthPlus whenever medically appropriate.
  • provide necessary covered services, as the result of a properly executed written referral authorization from a primary care physician, and to obtain and review any authorization from HealthPlus, for any subspecialty diagnostic procedure, which may exceed the scope of a participating provider’s area of practice and for which he or she has been credentialed.
  • preserve and enhance the member’s dignity.

Specialists are listed in the HealthPlus provider directory by primary specialty type.