Continuity of Care

New Members

New HPSM members can request continuity of care received from a current doctor who is not in HPSM’s network. Continuity of care may be allowed for up to twelve months. Approval for continuity of care depends on the following conditions:

1. The new HPSM member must have been seen by the non-contracted provider within the prior twelve months
   
2. The non-contracted provider must agree in writing to accept HPSM’s payment.

If a provider ends their contract with HPSM

If a member’s PCP or specialist terminates their HPSM contract, the member may request coverage for continued care up to 12 months. Approval for extended coverage depends on whether the member is being treated for certain medical conditions. The doctor also needs to agree in writing, with the payment terms in effect before contract termination.

Request continuity of care with an out-of-network doctor

Call Member Services. They will then notify you of HPSM’s decision. If you disagree with a decision to not approve your continuity of care request, contact Member Services and tell them you want HPSM to reconsider its decision.

Prior Authorization Requests (PAR)

Some medical services and medications such as physician administered drugs (PADs) or enteral nutritional supplements need to be approved by HPSM for your treatment before you receive them. This is called prior authorization of health care services. Your provider needs to request authorization when it is necessary. Not all services and medications require authorization.

How your provider requests authorization for services

• Your provider completes a form for a service or medication that requires prior authorization
• HPSM’s clinical staff review the medical necessity of the service requested
• When a request is denied, you and your provider will receive a letter that explains the reason for denial (Notice of Action)
• Some requests are deferred (decision postponed) because HPSM clinical staff need more medical information from your provider to make a decision. When this happens, HPSM sends you a letter to inform you that more information has been requested from your provider

If you disagree with a denial to approve an authorization request, you can contact HPSM Grievance and Appeals.