The Advantage Referral Program is a unique offering for WHA members. Through this program, WHA is able to offer a wider range of access to contracted specialty providers. This allows the health plan to be well-positioned in today’s competitive market. This program provides members with the opportunity to access specialty care outside of their assigned medical group.
WHA’s Advantage Referral Program provides members with access to specialists from the following medical groups:
- Dignity Health Mercy Medical Group
- Dignity Health Woodland Clinic
- Hill Physicians Medical Group
- NorthBay Health
- Providence
Members who are assigned to a PCP that belongs to any of the medical groups listed above are eligible for services under the Advantage Referral Program. (Note: Members that are covered under a plan provided through UC Davis do not have access to Advantage Referral. UC Davis Medical Group does not participate in this program).
The services obtained through the Advantage Referral program must be medically necessary and covered by the member’s benefit plan. The requested services must also be available within the members’ medical group. However, the member has a decision to see another specialist in another medical group. Advantage Referral allows a member to see a specialist outside of the PCP group for a limited number of visits and basic lab work. The services must be ordered by the member’s PCP.
The following are services that members can utilize via Advantage Referral without a PCP referral: Routine OB/GYN services for women (well-woman visits and routine prenatal care), as well as annual eye exams (Note: Not a covered benefit under all Plans. See Copayment summary to confirm coverage).
How does the referral work?
If a member’s PCP determines that specialty care is needed, members may choose to search WHA’s online Provider Directory to explore all specialty providers across the medical groups that participate in Advantage Referral. Members may also contact WHA’s Member Services Department to inquire about specialty provider options through Advantage Referral. It’s important to note that not all specialty providers will be able or willing to accept members. The decision to accept a member will be at the provider’s discretion. If a member determines they wish to see a specialty provider via Advantage Referral, this will need to be discussed with their PCP.
If determined to be an appropriate referral, the member’s PCP will need to submit a request to the Utilization Management Department of the member’s assigned medical group. The request is NOT directed to the Advantage Referral medical group. Typical turnaround time for routine prior authorization requests, including Advantage Referrals, is 5 business days and 72 hours for expedited requests. The member and PCP will be notified of the request outcome in writing. Members will receive a letter with details regarding the referral request.
Note: If you receive care from a WHA network specialist prior to receiving a referral, you may be liable for the cost of those services.
Is prior authorization required?
No, Advantage Referrals do not require prior authorizations (pre-approval) since your PCP has established medical necessity by requesting the services of a specialist.
What is covered?
An Advantage Referral authorization is valid for the initial specialty evaluation and up to two follow-up visits. Any services beyond basic office diagnostics will require prior authorization from the member’s medical group before services are rendered by the Advantage Referral specialty provider.
Additional services
Requests for additional visits, procedures, imaging, durable medical equipment or extensive lab work are to be submitted to the member’s Medical Group for review, not the medical group under which the member is receiving Advantage Referral services.
Please note, a referral outside of WHA’s network is not an Advantage Referral; a referral at the request of the PCP because the PCP’s Medical Group does not have a medically necessary service available is not an Advantage Referral.
If you have questions about WHA's Advantage Referral, call Member Services at 916.563.2250 or 888.563.2250 (TTY/TDD 711). The team is available Monday through Friday 8 a.m. to 6 p.m. (excluding holidays). You may also email a question to memberservices@westernhealth.com.