Pre-Notification and Authorization for Services
McLaren Health Plan Referral Process Authorization Requirements
McLaren Health Plan (MHP) promotes the traditional primary care relationship between physicians and their patients. Therefore, primary care physicians (PCPs) are given the responsibility and authority to issue referrals for care outside of the PCP office setting. MHP recommends that the PCP coordinate the entire episode of care to ensure the timely initiation and appropriate utilization of health services.
The Provider Referral Form is utilized by MHP when services outside of the PCP office setting are requested. The PCP must clearly identify on the Provider Referral Form if the member is covered under MHP's Medicaid or Commercial product. As a reference guide, the Provider Referral Form includes a Frequently Requested Services section on the front of the form, and a Complete Listing of Services that require pre-authorization on the back of the form.
MHP does not require any authorization for In-Network (contracted) specialty consultations, or for care provided in a specialist's office. However, pre-authorization is required, regardless of the contracted status of the physician for the following:
- Injections given in a specialist's office
- Chiropractic services for members less than 12 years of age
In summary, a completed Provider Referral Form and pre-authorization are required for:
- Any care that is referred to an Out-of-Network (non-contracted) physician
- Any service listed on the back of the Provider Referral Form
- Chiropractic services for members less than 12 years of age
- Certain injections (please call Medical Management for clarification)
Pre-authorization requests are subject to a medical review by MHP and may require additional information and/or documentation before a service can be approved.
When completing the Provider Referral Form:
- The PCP has the option of requesting an office consult with or without follow up visits
- The PCP must contact MHP to add any testing, outpatient procedures, or additional consults to other specialists, to the original office consult referral. Referrals are valid for the duration of the episode of care, not to exceed one year.
- A new referral form will be required if the episode of care exceeds one year.
Please visit the McLaren CONNECT portal to learn more about submitting your referrals through JIVA or contact Customer Service at 888-327-0671 for assistance with submitting referrals.