TMPPM 2009 > Provider Information > Managed Care > PCCM

7.7.16 Specialist Responsibilities

Specialists are responsible for furnishing medically necessary services to PCCM clients who have been referred by their primary care provider for specified treatment or diagnosis. While the specialist does not contract with PCCM, all facility services should be delivered in a contracted PCCM facility.

Specialists are responsible for verifying the eligibility of the referred client prior to providing treatment.

To ensure continuity of care for clients, the specialist must maintain communication with the client's primary care provider. This communication should ensure that the primary care provider's medical records adequately document the specialist services provided, all results or findings, and all recommendations. The specialist may use the lower half of the PCCM Referral Form for this purpose.

When a primary care provider refers a client to a specialist, the specialist should review the case with the primary care provider to fully understand the services being requested. Services requiring more than one visit should be coordinated with the primary care provider for approval of additional visits. Referrals from a primary care provider must be documented in both the primary care provider's and the specialist's records.

If a specialist determines that a client's condition warrants attention (e.g., hospitalization or diagnostic procedures), the specialist should seek authorization from the PCCM Inpatient/Outpatient Prior Authorization Department by telephone at 1-888-302-6167 or by fax at 1-512-302-5039.

Emergency treatment does not require authorization.

Refer to: "Facility/Hospital Services" .