You can manage referrals electronically using Authorization Manager, ConnectCenter, or a Direct Connection. Learn more about our technologies.
Note: A referral does not guarantee reimbursement. Member benefits and medical and payment policies may affect coverage and reimbursement.
You can use eTools to enter and check referrals for all members in managed care plans, including those out of area. Referrals can be entered for up to 99 visits, and are good for 365 days.
Important note for Authorization Manager: Procedure code 99243 is required, as well as a diagnosis. If no diagnosis is available, you may enter general symptoms (R68.89). Then continue as you would with an authorization request.
Verifying that a referral is on file and that the number of requested visits matches the services required helps facilitate the claims process and avoids unnecessary appeals or inquiries.
To search for an existing referral in Authorization Manager go to the View Authorizations screen. You can filter your list by typing "referral" under the column heading, Request Type.
With Authorization Manager, you can see both the Requesting Provider and the Servicing Provider.
To verify a referral in ConnectCenter, go to Verification> Authorization/Referral Status. Complete the required fields and click Submit.
If a referral is active, your results will look like this:
A primary care provider may recommend that a member consult with a specialist for care that the primary care provider can't provide. This is called a referral. The following managed care plans require notification of a referral for specialist care:
Specialist providers: For NEHP members with out-of-state PCPs, confirm the referral was received by the member’s home plan (which may not be Blue Cross Blue Shield of Massachusetts).
The primary care provider is responsible for coordinating the member’s care and entering the referral before the service is provided (at least one business day). A referral is valid for 365 days and allows the member to see a specialist for a certain number of visits (1-99).
If, for some reason, a referral cannot get entered before the service is performed, it can be submitted retroactively up to 90 days from the date of the actual visit. Enter the actual date of service as the start date.
Behavioral health services, urgent care, and Emergency Department services (for emergency conditions) don't require a referral.
You may need to request an authorization for coverage of some of these services. Either the primary care provider (PCP) or the designated specialist (with an open referral from the PCP, as applicable depending on the plan) can request authorization for outpatient services.
Please use an eTool to check the member's benefits and go to Clinical Resources>Prior Authorization for more information.
In addition, the following outpatient services don't require a referral when provided by an in-network provider: