EPO Plan. The Metro Health Select an exclusive provider organization plan, which includes the following general specifications:
EPO Plan. Members will select a Primary Care Provider (PCP) from the Tier 1 Prime Healthcare Network Directory or the Tier 2 Blue Cross BlueCard PPO Network. Specialty and Facility care will be coordinated through a referral process with the PCP and the Prime Healthcare Utilization Review department. Referrals submitted to Prime UR with all pertinent information (i.e. CPT, Diagnosis codes, clinical information, also known as a clean referral) will be processed within seven business days from the date of receipt. Additional time may be necessary if the referral is missing pertinent data and Prime UR must contact the referring provider for additional information. No referral is necessary for the following services: PCP Office Visit, Pediatric Office Visit, Annual Well Exam, Urgent Care or Emergency Room Visit. If determined by Prime UM, Facility or specialist care not available in Tier 1 RI shall be referred to the Tier 2 Network and be paid out at tier one cost levels.
