• Complying with Hometown Health ’ s Utilization Review and Quality Improvements programs ;
• Complying with all requirements for credentialing and re-credentialing and participation in the Hometown Health provider network ;
• Complying with the referral authorization process as outlined in the Medical Management section of this manual .
Specialist Physicians
Specialists contracted with Hometown Health provide specialty care to our members as follows :
• Upon receipt of an authorized referral ( if required ) for a member from a participating PCP , evaluate , diagnose , or treat the member as indicated on the authorized referral ;
• Maintain communication with the PCP ’ s office regarding the continuing care of the member ;
• Some plans require prior-authorization referrals from Hometown Health for specialty care . Please refer to the Authorization Matrices located on Link . In the event that a Prior Authorization is required , failure to obtain the authorization prior to rendering services may result in a “ Hold Harmless ” claims denial where the physician may not collect payments from the member for services denied by Hometown Health including the applicable copayments ;
• Submitting medical records upon request to another provider or to Hometown Health in accordance with the terms of the provider contract ;
• Comply with Hometown Health ’ s Utilization Review and Quality Management programs ;
• Comply with all requirements for credentialing and re-credentialing and participation in the Hometown Health provider network ;
• Obtain authorizations from Hometown Health for procedures and request additional office visits from the PCP prior to services being rendered , when required .
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