QUEST Integration - Responsibilities of the Specialist

Original Effective Date:

08/01/1994

Current Effective Date:

01/01/2015

The following are the responsibilities specialists are expected to meet.

• Have a patient's PCP referral before treating a patient unless the service is an emergency or an inpatient consultation was requested by an attending physician (follow-up care for patients first seen in an emergency must have PCP referral)
• Forward medical records, reports and other documentation regarding patient care to the PCP
• Obtain precertification of services when needed if services will be provided by the specialist

Accessibility Standards

The following accessibility standards have been adopted by HMSA's Plan for QUEST Integration Members for both PCPs and specialists:

• Immediate care and without prior authorization for emergency medical services.
• Appointments within 24 hours for urgent care and for PCP pediatric sick visits.
• Appointments within 72 hours for PCP adult sick visits.
• Appointments within 21 days for behavioral health (routine visits for adults and children)
• Appointments within 21 days for PCP routine visits for adults and children.
• Appointments within 4 weeks or within sufficient timeliness to meet medical necessity for visits with a specialist or for non-emergency hospital admissions.

Delivery of Services

Actions taken by HMSA and its Pre-Authorization Unit relate solely to determinations as to whether a service meets the criteria for payment under the QUEST Integration plan. HMSA’s Plan for QUEST Integration Members does not control or direct whether or how physicians provide services. Physicians are responsible for the clinical decisions regarding care and treatment of patients and for the quality of those services.

Revision History