The Advantage Referral Program -- an operational guide for staff & providers

What are the advantages of Western Health Advantage (WHA)?

WHA is a health maintenance organization (HMO) founded in 1997 by local healthcare institutions Mercy Healthcare/Catholic Healthcare West, UC Davis Health System, and NorthBay Healthcare. Built differently as a provider-owned, not-for-profit plan, WHA avoids the inefficiencies of big, bureaucratic HMO?s resulting in a more patient- and physician-friendly health care program.

The Advantage Referral Program is one example of an innovative WHA offering which draws on the strengths of contracted medical groups to the benefit of members and participating physicians.

The contracting department of each of WHA's medical groups has worked with WHA to develop a program to protect your group from financial harm and to monitor any potential problems in the future. Advantage Referral meetings are held regularly to review and monitor the "cross-over" performance of each medical group.

Please call your medical group's Utilization Review (UR) Department or WHA for any questions regarding the Advantage Referral Program.

What is the Advantage Referral Program?

WHA implemented this unique program as a way to expand our members? choice of specialists. The Advantage Referral Program allows a patient to select a PCP in one medical group and be referred to a specialist in another contracted WHA medical group, as long as the specialist agrees to participate in the Advantage Referral Program. This program gives patients more choice since they are not locked in for specialty care.

Not all contracted practitioners participate in the Advantage Referral Program. Doctors that do not participate are identified in WHA's provider directories.

Self-referred OB/GYN services for women and annual eye exams are included in the Advantage Referral Program but do not require a PCP referral or prior authorization, as long as the provider is listed in the WHA provider directory. `

How do I refer a WHA patient upon request to a physician in another WHA medical group?

WHA patients are seen in your office just like any other patient. If the PCP believes a specialist referral is needed, that PCP will make the referral following his/her usual process. If the WHA member requests to go to a specialist within another WHA medical group, the PCP can refer the patient to that specialist for evaluation and treatment.

Is prior authorization required for the WHA member when they want to go to another group's specialist?

No. Three (3) initial visits, routine lab and plain film x-rays can be performed at the specialist?s office without prior authorization. Some specialists are allowed to do some tests or biopsies immediately, if necessary.

What happens if the specialist wants to do further tests or procedures?

The specialist's office must contact the PCP's office to get authorization for non-emergent procedures and scheduled tests. The PCP's group completes the authorization based on medical necessity, but the specialist may perform the procedure at his/her group's own facility following the authorization approval.

As a specialist, how do I know if a WHA member is in my assigned group or has "crossed-over" from another WHA physician group?

Please make sure that your front office identifies the patient's PCP and medical group. It will be important to have the PCP's phone number handy for obtaining authorization if procedures or scheduled tests are needed. The PCP will also appreciate prompt follow-up on the patient's work-up and condition.

What happens if a WHA member is admitted emergently to a WHA hospital other than the PCP'S affiliated facility?

The WHA member has the option of staying in the treating facility. You may want to discuss transferring the patient back to the PCP?s affiliated facility; but if the patient indicates they do not want to be transferred, they should be allowed to stay in that facility until discharged. Please contact your UR Department if this situation should arise.

If a patient is admitted to a non-contracted WHA facility, the patient may be transferred to the PCP's affiliated facility when stabilized for transfer.

Advantage Referral quick reference

• With a PCP referral, WHA commercial members may elect to see a specialist that participates in the Advantage Referral Program in the following WHA medical groups: Hill Physicians Medical Group, Mercy Medical Group, NorthBay Healthcare, UC Davis Medical Group, Woodland Healthcare, Golden State Physicians Medical Group and Solano Regional Medical Group.
• With a PCP referral, WHA Medicare members may elect to see a specialist that participates in the Advantage Referral Program in the following WHA medical groups: Mercy Medical Group, UC Davis Medical Group, Woodland Healthcare and Golden State Physicians Medical Group.
• Self-referred obstetrical and gynecological services for women and annual eye exams are included in the Advantage Referral Program but do not require a PCP referral or prior authorization, as long as the provider is listed in the WHA provider directories.
• Submit an "Advantage Referral Form" or similar UR form to your UR Department that states, "Patient elects cross-over". This will be used for tracking.
• Specialists should contact the PCP to request authorization for scheduled tests, surgeries or visits beyond the initial three (3) visits. Submit request forms for medical necessity review.
• If you have questions, call your UR/UM Department or WHA.