FAQs for PCPs

What is the Priority Health Spine Centers of Excellence program?
Spine Centers of Excellence are led by physical medicine and rehabilitation providers whose focus is the non-operative, comprehensive management of spine problems. For patients whose condition does not require urgent or emergent surgical evaluation, Priority Health requires evaluation in a Spine COE before surgical evaluation.

Who can be referred to a Spine COE?
Each physician has a different comfort and experience level treating spine-related problems. At the point where you are at your limits, you are welcome to refer to a COE, including before or after failure of conservative care. Obtaining an imaging study prior to referral is not necessary. The Center of Excellence will not only confirm the diagnosis, but also provide treatment recommendations to you and to your patient. Centers may use shared decision-making tools to review the different treatment options and their risks and benefits.

Why is Priority Health implementing a Spine Centers of Excellence program?
Priority Health is committed to providing access to high-quality, affordable health care. There is a growing body of evidence that an increasing number of patients with neck and back pain can be treated non-operatively. Evidence also shows that multi-disciplinary spine clinics can reduce back surgery rates. This is consistent with Priority Health data that show an inverse relationship between physiatry utilization and spine surgery rates.

What are the goals of a Spine Center of Excellence?
The primary objective of the program is to ensure that all patients with neck and back problems have timely access to a comprehensive non-surgical, medical evaluation.

What is the process for a Priority Health member to be seen at a Spine Center of Excellence?
Any participating physician can refer a patient to a Center of Excellence. A referral does not require prior approval by Priority Health. However, all referrals for spine-related problems to a spine surgeon require prior authorization and plan approval.

What are the primary referral requirements in this program? The referral requirements are as follows:

1. Prior authorization is required for all referrals to orthopedic or neurosurgeons for back or neck pain and other spine-related complaints as outlined in the medical policy.
2. Evaluation by a Priority Health Spine Center of Excellence is required prior to referral to an orthopedic or neurosurgeon for back or neck care/evaluation unless there is an acute indication for surgical evaluation (see #3).
3. Surgical evaluation of back or neck problems does not require a Spine COE evaluation for the following (prior authorization still required):
4. Evidence of tumor, infection or fracture.
5. New onset of bowel incontinence, or bladder incontinence, or retention (cauda equina).
6. Progressive upper or lower extremity weakness or myelopathy. Myelopathy is defined as cord compression with clinical bilateral "long tract signs" and potential for bowel and bladder control compromise. Rarely if ever would this be present with a mild weakness or unilateral foot drop. True acute myelopathies require urgent evaluation to rule out a surgical emergency.
7. Follow-up to emergency care provided in the ER or inpatient setting.
8. The referral requirement does not apply in the following circumstances:
9. Non-spine-related care provided by neurosurgeons or orthopedic surgeons.
10. Care provided in an inpatient or emergency department.
11. Patients <18 years of age.

What members and products does the prior authorization requirement apply to?
Prior authorization is required for all members except those with a Priority Health Medicare plan. Members with PriorityHMO^SM, PriorityPOS^SM, PriorityPPO^SM and Priority Health Medicaid all require prior authorization.

If I think a patient needs to see a surgeon right away, what is the process?
Complete the Priority Health surgical prior authorization form (499KB PDF) and indicate "urgent." If it meets one of the requirements above, requests will be completed the same day. All other requests will be reviewed and a decision made within 48 hours.

Is a prior authorization form required for referral to a Spine COE?
No, but the COE may have its own referral and information collection forms. Prior authorization is only needed for surgical evaluations and surgery.

Can I still refer directly to therapists or to pain specialists?
Yes. Alternatively, you can refer to a COE that can use its consultants. No plan authorization is required.

Can I refer to a COE before physical therapy or pain specialists?
Yes. Our intent is to ensure that an accurate diagnosis is made prior to prolonged treatments. If the patient is not responding, consider a referral to a COE.

I’m concerned about timely access. Do the centers have access standards?
As part of the agreement regarding participation in the Centers of Excellence program, the centers agree to evaluate either in person or telephonically all patients within 48 hours. The centers' goal is to see acute patients 10 days.

Can I still refer to physiatrists who are not part of a Spine COE?
Yes.

How will I be kept informed?
The Centers of Excellence also have communication standards to meet. As specified in the COE requirements, a consultation note should be sent to the referring physician within four days of the visit.

What about patients who already have an existing relationship with an orthopedic or neurosurgeon?
You must still obtain prior authorization. You or the surgeon may request services. Priority Health will evaluate the request and take into consideration whether the patient has already had surgery or not. If not, we would require evaluation in a Spine Center of Excellence prior to receiving further care with a surgeon.

Who is responsible for obtaining authorization for a surgical consultation? What about for surgery?
The referring physician, whether the primary care physician or another provider, is responsible for the submission. The operating surgeon is responsible for obtaining the prior authorization for surgery.

What happens if prior authorization is not obtained?
Claims will be denied. The member cannot be held liable unless he or she is informed prior to a visit that he or she may be liable and signs a waiver acknowledging liability.

What if a patient still wants to see a surgeon after evaluation in the Spine Center of Excellence?
The intent of the program is to have patients understand all the medical and surgical options available to them. If the patient or the primary physician still desires to see a surgeon, the center or the primary care physician can refer to a surgeon. Prior approval by the plan is required.

Who can make referrals to a Spine Center of Excellence?
PCPs, ER physicians or urgent care centers, and other specialists, including surgeons.

Can a Center of Excellence refer a patient directly to a spine surgeon?
Yes, but, as noted above, this requires prior plan approval. If, after the Center of Excellence evaluation, surgical evaluation is indicated, Priority Health will approve the physiatrist's request for consultation. Primary care physicians can use an optional referral form to indicate preferred surgeons or therapist.

Can a Spine Center of Excellence refer a patient directly to therapists, pain specialists, neurologists or other specialists?
Yes; however, Priority Health strongly encourages each Center of Excellence to work with the primary care physician when making referrals.

Whom do I call if I have more questions?
Contact your Priority Health physician account executive (PAE) directly or through the Provider Helpline at 616 942-4765 or 800 942-4765.