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Members - Referrals and Authorizations
 

As an HMO Member how do I know when to obtain a referral and authorization for services?

You may access care at your GVHP Family Health Center at any time. Simply call the phone number listed on the front of your Membership card 24 hours a day seven days a week. Care at your Family Health Center or the GVHP Urgent Care Center does not require any referral or authorizations.

Emergency Care also does not require authorization. If your condition is an emergency, go to the nearest hospital right away. Or if you can call your GVHP Family Health Center for help. If you are unable to call before going, then call when medically possible or within 48 hours. This will allow for your Family Health Center to plan for your follow-up needs and coordination of care.

In addition, at Grand Valley Health Plan, there are no insurance limits placed on specialists’ care, testing, or treatments. Your Family Health Center Practitioner, not The Health Plan, decides when the visits to specialist, testing or treatments are necessary. All referrals and visits to medical specialist, including testing or treatment must be pre-approved and set up by your Family Health Center to ensure integration and coordination of care.

However, there are just a few “special services” that need to be reviewed and prior authorization from GVHP insurance company staff. This review is done by the Vice President of Medical Affairs (VPMA). The VPMA is also known as the medical director.

These “special services” are:

  • Out-of-Area Care
  • Cosmetic procedures
  • Investigational or Experimental Procedures
  • Requests for New Technology
  • Bariatric Surgery
  • Transplants
  • There is a process for looking at these requests. It is called the GVHP Medical Opinion Process. Your Family Health Center Practitioners help in this process. You only need to speak with him or her about treatment options. The Family Health Center Practitioner makes the request and completes the necessary paperwork.

    In addition you may also call GVHP Customer Services at 616-949-2410 or e-mail us at cs1@gvhp.com and we would be happy to answer any of your questions.