Federal and Michigan law allows female members to access an affiliated OB-GYN for services, without a prior authorization or referral. In Michigan, examples of such services include annual well-woman examinations and routine obstetrical and gynecologic care. HealthPlus encourages HMO members to ask their primary care physician (PCP) to assist in the selection of; an in-plan OB/GYN . PPO members can self-refer to an in-plan OB/GYN. A standard annual well-woman exam is defined as: a preventive medicine examination, which would include a comprehensive examination, counseling, anticipatory guidance, risk factor reduction interventions and the ordering of appropriate laboratory diagnostic procedures. A Depo-Provera injection or the insertion of Norplant can also be provided during the annual well-woman exam or during a post-partum visit.
A referral is not required for antepartum (in the case of a miscarriage, physician change) or for routine obstetrical services. A HMO member should utilize the PCP’s primary hospital delivery, unless the hospital does not provide obstetrical services or an emergent or high risk situation occurs. An in-plan referral may be required if the patient does not use the PCP’s primary hospital. PPO members should select an OB/Gyn with privileges at their preferred hospital. A referral will be required for HMO members who require the attention of a Perinatologist. . PPO members may self refer to an in-plan Perinatologist.
Routine obstetrical services are defined as:
- Prenatal visits
- Related lab work
- Related ultrasounds
- Chorionic villi sampling
- Delivery, vaginal or cesarean
- Postpartum visit
Access to infertility services is determined by a member’s benefits/coverage, as well as medical necessity criteria. This benefit is limited; generally 12 month benefit period, and begins with the first intrauterine insemination. For exclusions and member liability, the member’s benefit/coverage documents should be referenced.
A referral is required for HMO members.
An Infertility Evaluation form is required for BOTH HMO and PPO members.
HMO member's must submit the evaluation form submitted with the referral request for infertility services. PPO members must have the evaluation form completed and submitted to HealthPlus for review and approval of services, prior to the services being rendered.
For more information about referrals for obstetrics and gynecological procedures, please contact the HealthPlus Prior Authorization and Referral Management Department at (800) 733-6360 or (800) 942-5974, or by email to Referrals1@healthplus.org.