20-841.04. Standing referrals to network health care professionals; definition

A. Any corporation that offers a health benefits plan shall establish a procedure by which a subscriber may apply for a standing referral to a network health care professional. The corporation shall provide a subscriber with a standing referral if all of the following conditions are met:

1. The subscriber is a covered member of that corporation.

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

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

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

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

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

B. The corporation may limit the number of visits and time period for which a subscriber may receive a standing referral.

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

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

E. This section does not apply to any corporation that holds a certificate of authority to operate either as a dental service corporation or an optometric service corporation.

F. 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 corporation to provide services in a specialty discipline that is recognized by an American medical specialty board.