Please be advised that the process may go through multiple steps over the course of 1-3 business days as needed and as follows:
1. Your LCTHC Provider initiates the referral request
The LCTHC PRC Referrals Department cannot process a referral if your provider has not issued one. All routine referrals are processed in the order they are received, with priority made for referrals marked “STAT/Urgent” or “ASAP” by your provider as deemed necessary depending on your health condition. STAT/Urgent referrals are processed within 24 hours and ASAP referrals are processed within 48 hours.
2. The LCTHC PRC Referrals Department reviews all information is complete
The LCTHC PRC Referrals department will review all information to ensure all adequate records are included depending on the requirements of the specialist (labs, imaging, order forms, previous medical records, chart notes, documentation, etc.). If any documentation or records are missing, the referral cannot be processed, and The PRC Referrals department will send the referral back to your provider to correct, order additional tests, and/or include the appropriate information.
3. The PRC Referrals Department reviews patient insurance information
The LCTHC PRC Referrals department will review the patient’s insurance information and prior-authorization/RAF requirements for each referral. If you have requested a specific specialist, and that specialist does not accept your insurance, the PRC Referral staff will refer you to a specialist that does accept your insurance (if available). Requests for specific specialists cannot always be fulfilled as these may depend on various factors including type of insurance accepted or specialist availability.
4. Medi-Cal Partnership Health Plan patients must have LCTHC assigned as PCP
If you are a Native American patient enrolled in Medi-Cal/Partnership Health Plan and you are currently assigned to a PCP other than LCTHC, we will be unable to process any referrals for you and will send you a letter stating your options (i.e., call Partnership and switch your PCP to LCTHC or call Partnership and notifty them that you are Native American and this requirement does not apply to you, or go to your assigned PCP to request a referral). It is your responsibility to proceed as you choose at this point as LCTHC cannot process any referrals for patients when we are not the assigned PCP with their MediCal/Partnership Health Plan.
5. LCTHC may encounter difficulties/delays or be unable to issue referrals for EPO/HMO/Worker’s Comp Insurance patients
If you are enrolled in an EPO or HMO insurance, LCTHC is not an EPO or HMO provider and we may have difficulties obtaining insurance authorization to find a specialist within your network. You may have to see a provider within your network to proceed with your referrals. If you have a Medicare HMO plan, our Patient Resource Advocate may reach out to you to provide you with information and assist with switching your Medicare HMO plan to a standard Medicare plan if you choose to do so. If you are being seen for a Worker’s Comp claim, LCTHC is not a Worker’s Comp provider, therefore you will have to contact your Worker’s Comp insurance to get set up with a provider within your Worker’s
Comp network.
6. Services and tests may require prior authorization from your insurance
Depending on your insurance, certain tests may require prior authorization (i.e., MRI, CT Scan). Once that authorization is obtained for a certain facility, if you do not obtain the services or choose to go to a different facility, the authorization request will have to be re-submitted and you may have to wait additional time before being able to schedule. LCTHC has no control over what your insurance does and does not approve, and we will do everything possible to submit the documentation required for such services.
7. Referrals are not a guarantee of payment
A referral is a request for medical care from a specialist, not a guarantee of payment. You are responsible for providing accurate medical insurance information to LCTHC and to the specialist as well as making payment arrangements as needed for your visits.
8. PRC eligible patients are responsible for maintaining their eligibility for PRC funding
If you are an eligible Native American that has met all Purchased/Referred Care eligibility requirements, please note that your referral will state whether the service is covered or not. Again, a referral is not a guarantee of payment. All referrals must be renewed every six months in order for the PRC program to cover your services. You are responsible for maintaining your eligibility (residency, alternate resource, current referral, and all other PRC requirements). If the provider that we refer you to then refers you to another provider, you must contact your LCTHC provider to issue a new referral for that other provider in order to have those other services covered by LCTHC. If you have any questions regarding your PRC eligibility or the PRC program, please contact the PRC office directly.
9. When all information is complete, referral is processed
Once all documentation is received by the PRC Referrals department, they will send all information to the specialist via fax and will mail you a copy of the referral which will include the specialist’s contact information (name, address, phone number, reason for referral). It is your (patient) responsibility to provide us with your current contact information (address and phone number). We will mail the referral to the address we have on file for you, and the specialist will attempt to contact you at the phone number you have provided to us. A member of the PRC Referrals department will also contact you via phone to inform you that your referral has been processed and provide you with the pertinent details and offer any further assistance.
10. It is patient’s responsibility to schedule appointment with the specialist
If by the time you receive a copy of your referral in the mail, you have not yet heard from the specialist’s office, it is your responsibility to contact the specialist’s office directly at the phone number listed on your referral to schedule your appointment. Please note, most if not all specialist offices will contact you directly to schedule your appointment. Therefore, it is of utmost importance that you provide us with your current address and phone number at all times and that you answer your phone and/or have a working voicemail where the specialist’s office can leave you a message so you may return their call at your earliest convenience. If you are encountering difficulties and require additional assistance with scheduling your appointment, you may contact our Patient Care Navigator at extension 1123 and she will help as needed. If the specialist’s office is unable to contact you after a few attempts, they will discard your referral and will no longer have record of it. At that point, LCTCHC will have to re-submit your referral to the specialist’s office.
11. Specialist’s offices all have specific policies for scheduling
Each specialist’s office is different and will review/approve/reject/schedule depending on their individual office policies. Please be advised that their timeline on reviewing a referral and/or scheduling an appointment for you is beyond the control of the LCTHC Referral Department.