A referral is only required when a service is needed outside of the NPHO network. Authorization will only be given for those services which are truly not available in the NPHO network. Authorization is not granted based on convenience. Without prior authorization, you are fully responsible for all costs. Additionally, there are not any benefits paid (except meeting the definition of a true emergency) for services provided out of network.
An Oklahoma (Registered Nurse) RN Care Coordinator will review the request and approve for pre-defined cases. The medical director will grant overall approval and approval for the more complex cases.
If a request has been denied, a list of eligible network providers will be provided as alternative options. If a member wishes to appeal a denied request, they can complete an appeals form and submit to the Care Coordination Team for review. Review of the appeal may require a conference between the medical director and the referring provider. All decisions made after an appeal will be final.