20-1057.01. Standing referrals to network health care professionals; definition

A. A health care services organization shall establish a procedure by which an enrollee may apply for a standing referral to a network health care professional. The health care services organization shall provide an enrollee with a standing referral if all of the following conditions are met:

1. The enrollee is a covered member of that health care services organization.

2. The enrollee has a disease or condition that is life threatening, degenerative, chronic or disabling.

3. The enrollee's primary care physician or registered nurse practitioner in conjunction with a network health care professional determines that the enrollee's health care requires a network health care professional's expertise.

4. The enrollee's primary care physician or registered nurse practitioner determines that the enrollee's disease or condition will require ongoing medical care for an extended period of time.

5. The standing referral is made by the enrollee's primary care physician or registered nurse practitioner to a network health care professional who is responsible for providing and coordinating the enrollee's specialty care.

6. The network health care professional is authorized by the health care services organization to provide the services under the standing referral.

B. The health care services organization may limit the number of visits and time period for which an enrollee may receive a standing referral.

C. If the enrollee receives a standing referral or any other referral from the enrollee's primary care physician, that referral remains in effect even if the primary care physician leaves the health care services organization's network.

D. If the treating health care professional leaves the network or the enrollee ceases to be a covered member, the standing referral expires.

E. For the purposes of this section, " network health care professional" means a practitioner of a health profession as defined in section 32-3101 who is under written contract with the health care services organization to provide services in a specialty discipline that is recognized by an American medical specialty board.