When ordering services for HMO, POS, and Direct POS members, the ordering provider (including specialists) must utilize the capitated site selected by the member’s primary care physician for these specialties:
If a capitated site cannot perform the service, that site is required to make arrangements for the service to be provided by one of its subcontractors. Out-of-capitation exception requests should be limited and are approved only when the capitated site cannot meet the member’s medical requirements for the ordered services.