Providers
Chapter 11
Section 3.1
Physician Referral And Supervision
Issue Date: December 18, 1985
Revision:
1.0 ISSUE
1.1 In order
to be considered for benefits on a fee-for-service basis, the services
of the following individual professional providers of care may be
provided only if the beneficiary/patient is referred by a physician
for the treatment of a medically-diagnosed condition.
1.2 A physician
must also provide continuing and ongoing oversight and supervision
of the program or episode of treatment provided by the following
individual providers:
• Licensed Registered
Nurses (RNs).
• Licensed
Practical Nurse (LPN) or Licensed Vocational Nurse (LVN).
• Audiologist.
• Pastoral Counselors.
• Supervised Mental
Health Counselors (SMHCs).
2.0 POLICY
2.1 A physician
must establish a diagnosis which, in order to be considered for
benefits, must describe a covered condition. This means the physician
must actually see the patient, do an evaluation and arrive at an
initial diagnostic impression prior to referring the patient. Any
change in the referral diagnosis must be coordinated with the referring
physician.
2.2 The overall management of the patient rests
with the physician and, in order to assure appropriate case management,
coordination must be made with the referring physician on an ongoing basis.
Physician supervision means the physician provides overall medical
management of the case. The referring physician does not have to
be physically located on the premises of the provider to whom the
referral is made. Communication back to the referring physician
is an indication of medical management.
2.3 Military physicians may refer
patients to civilian providers. Because of the mobility of military physicians
due to transfers, retirements and discharges, if the original referring
physician has relocated, another military physician may assume responsibility
for the case upon review of the Military Treatment Facility (MTF)/Enhanced
Multi-Service Market (eMSM) clinical record, a narrative of the patient’s
present status and the proposed treatment plan.
3.0 EXCLUSION
Any services provided prior to examination
and subsequent referral by a physician.
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