South Carolina Code 38-33-325. Obstetrician-gynecologist services; referrals; authorization for services; member notification of plan provisions
(B) For any continuing treatment resulting from obstetrical or gynecological, or both, complications diagnosed during the two visits for a calendar year, authorization must be made for medical necessity directly by the health maintenance organization. Written communication should be sent by the obstetrician-gynecologist to the patient’s primary care physician regarding the condition being treated within a reasonable time after each visit.
Terms Used In South Carolina Code 38-33-325
- Enrollee: means an individual who is enrolled in a health maintenance organization. See South Carolina Code 38-33-20
- Health care services: means services included in furnishing an individual medical or dental care or hospitalization or incident to the furnishing of care or hospitalization, and other services to prevent, alleviate, cure, or heal human illness, injury, or physical disability. See South Carolina Code 38-33-20
- Health maintenance organization: means a person who undertakes to provide or arrange for basic health care services to enrollees for a fixed prepaid premium. See South Carolina Code 38-33-20
- Provider: means a physician, dentist, hospital, or other person properly licensed, where required, to furnish health care services. See South Carolina Code 38-33-20
(C) A health benefit plan must notify its members of the provisions of this subsection (A). The information must be provided in the Summary Plan Description materials and enrollment materials.
(D) For purposes of this section:
(1) "Health benefit plan" means a health maintenance organization, a preferred provider plan, an exclusive provider plan, or other managed care arrangement plan;
(2) "Health care services" means the full scope of medically necessary services provided by the participating obstetrician-gynecologist in the care of or related to the female reproductive system and breasts.