WHA's Advantage Referral Program

Through collaboration between WHA and its contracted medical groups/IPAs, the Advantage Referral Program was developed to expand the members' choices of specialty physicians. Advantage Referral allows members to access any appropriate participating specialist in the Plan's network rather than limiting members to care from doctors who have a direct relationship with the member's primary care physician (PCP), medical group or IPA. Members may request to be referred to any of the WHA network specialists that participate in Advantage Referral. The WHA Provider Directory designates the providers who do not participate in the Advantage Referral Program. The Advantage Referral Program also includes OB/GYN services for women and annual eye exams although these services do not require a PCP referral or Prior Authorization, as long as the specialist participates in Advantage Referral. In addition, WHA has worked with the medical groups/IPAs and hospitals to protect them from any financial harm from this program.

How do I refer a WHA patient to another WHA network specialist?

If medically appropriate, you will provide a written referral to your medical group's/IPA's Utilization Management Department that will be entered into the authorization system to generate a "tracking number". This "tracking number" allows appropriate adjudication of claims. The member will receive a notification with details of the referral. If a member receives care from a WHA network specialist without first receiving a referral, the member may be liable for the cost of those services.

Is Prior Authorization required for WHA members when they want to access a WHA network specialist in another medical group/IPA?

No, Advantage Referrals do not require Prior Authorizations (pre-approval) since the PCP, by requesting the services of a specialist, has established medical necessity. However, a referral is recommended for tracking purposes and for appropriate reimbursement. After the PCP submits an Advantage Referral request to the Utilization Management Department of his/her medical group/IPA, the specialist is notified regarding the number of visits and/or timeframe allowed to provide the services. For example, up to three visits are included in the initial Advantage Referral. The specialist can provide "routine services", such as ordering lab work and plain film x-rays without obtaining permission from the medical group. If "special" tests, procedures, or surgery are recommended by the specialist, a separate referral needs to be generated by the member's PCP and pre-approval is required from the member's medical group to ensure coverage.

Prior Authorization is required for:

• Services from non-Participating Providers except in Urgent Care or Emergency situations. For example, a Covered Service may be medically necessary but not available from Participating Providers. Then, the member's physician must obtain Prior Authorization from WHA or its delegated medical group/IPA before the member receives services from a non-Participating Provider;
• Care with a specialist physician that extends beyond an initial number of visits or treatments;
• Physical therapy, speech therapy and occupational therapy;
• Rehabilitative services (cardiac, respiratory, pulmonary);
• All hospitalizations;
• All surgeries;
• Non-emergent medical transport or ambulance care;
• Second medical opinions;
• Some prescription medications (if prescriptions are covered under the member's plan);
• All infertility services (if infertility services are covered under the member's plan);
• Scheduled tests and procedures;
• Other services if the member's medical group/IPA requires Prior Authorization (ask the member's PCP);
• Transgender surgery and related inpatient and outpatient treatment or services.

Billing for Advantage Referral Services

If you are a specialty provider rendering an Advantage Referral service to a WHA member who is assigned to a PCP from another group, you should send the bill for services directly to the member's affiliated group, not WHA, for reimbursement. Your office staff should be directed to mark the bill as an Advantage Referral service to ensure faster claims processing.

The member's affiliated group/IPA and PCP are listed on his/her WHA ID card. This information can be confirmed by calling WHA's Member Services Department at (916)563-2250 or (888)563-2250 toll-free, Monday through Friday, 8:00 am to 5:00 p.m., or by searching the WHA online Provider Directory or online eligibility verification.