FAQs for Surgeons
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Referrals
What is the Priority Health Spine Centers of Excellence program?
Spine Centers of Excellence are physiatrist-led clinics 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.
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 multi-disciplinary spine clinics can reduce back surgery rates. This is consistent with Priority Health data that shows an inverse relationship between physiatry utilization and spine surgery rates.
What are the goals of a Spine Center of Excellence?
This initiative has three objectives:
- To ensure all patients with neck and back pain have timely access to a comprehensive medical evaluation
- To provide resources to ensure that all patients are fully informed of all treatment options
- To coordinate both surgical and non-surgical care and management
How does a practice/provider become a Spine Center of Excellence?
The center must meet specific criteria in the following areas:
- Financial independence
- Core staffing that includes a physiatrist, therapist and care coordinator
- Service and communication standards
- Aligned medical and surgical consultants
- Diagnostic services
- Use of evidence-based guidelines
- Use of shared decision-making tools for common conditions
- Collection and reporting of clinical outcomes
Referrals
What are the primary referral requirements in this program?
The referral requirements are as follows:
- 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.
- 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).
- Surgical evaluation of back or neck problems does not require a Spine COE evaluation for the following (prior authorization still required):
- Evidence of tumor, infection or fracture.
- New onset of bowel incontinence, or bladder incontinence, or retention (cauda equina).
- 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.
- Follow-up to emergency care provided in the ER or inpatient setting.
- The referral requirement does not apply in the following circumstances:
- Non-spine-related care provided by neurosurgeons or orthopedic surgeons.
- Care provided in an inpatient or emergency department.
- Patients <18 years of age.
What products does this apply to?
This applies to all Priority Health products, including Priority Health Medicare plans.
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.
If care is authorized, what is the duration of the authorization?
For consultations, a total of 4 visits in 12 months will be authorized. For surgical approvals, a total of 4 additional visits will be authorized. These visits will be in addition to any office visits provided during the global period. Office visits during the global period are not covered services.
What about patients who already have an existing relationship with an orthopedic or neurosurgeon?
Prior authorization must still be obtained. 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. This is the first circumstance in which we will allow surgeons' offices to obtain the prior authorization directly.
Can an emergency department refer a patient to a surgeon?
Yes, but prior authorization by Priority Health is required. This is the second circumstance in which we will allow surgeons' offices to obtain the prior authorization directly.
How do I verify that the patient has been seen in a Priority Health-approved Center of Excellence?
The COE will send notes to the surgeon's office upon request or when referred. Offices may also contact the Center of Excellence to verify the patient has been seen. A list of approved centers is available on this website, or by calling your physician account executive (PAE) directly or through the Provider Helpline.
What should I do if a patient calls to schedule an appointment?
The patient can be told that prior authorization from Priority Health is required. Emergency requests can be handled the same day.
Will I need prior authorization for services other than back or neck pain?
No.
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 is the process for a Priority Health member to be seen at a Spine Center of Excellence?
Any participating physician can refer someone to a Center of Excellence. A referral does not require prior approval by Priority Health. However, all referrals for back and neck pain to a spine surgeon, either an orthopedic surgeon or a neurosurgeon, require prior authorization and plan approval.
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 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.
What about patients who already have an existing relationship with an orthopedic or neurosurgeon?
Prior authorization must still be obtained. 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 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. Priority Health has developed a voluntary referral form to the Spine COE that allows primary care physicians to indicate which therapists or specialists they prefer to use.
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. Again, Priority Health has developed a voluntary referral form to the Spine COE that allows primary care physicians to indicate which therapists or specialists you prefer to use.
How have primary care providers been educated?
Priority Health has used several methods of educating primary care providers regarding both the availability of the Spine Centers of Excellence and the requirement for prior authorization of surgical consultation. Methods include direct mailings, PHO leadership and office manager education, and Priority Health physician account executive office visits.
Whom do I call if I have more questions?
Please contact your Priority Health physician account executive (PAE) directly or through the Provider Help Line.
Also see:
FAQs for PCPs
FAQs for Centers
