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 a referral for specialist care:
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).
Members can only be referred to other providers who participate in the member’s network. You must notify us of the referral using one of the eTools(
- Please use a technology like Online Services(
) to check whether a referral is in place before treating a managed care member.
- If there is no referral on file, please contact the member’s primary care provider. If you treat a patient without a referral, you cannot bill the member for the service unless you get the member’s prior written consent stating that he or she will be responsible for payment.
- To ensure that the member understands the written consent allows you to collect fees for non-covered services, the member must sign the waiver on the date of service. It does not need to list the specific service that won’t be covered, but it should indicate that if the member does not have the required referrals, the member will be responsible for charges that are not covered.
- If your initial claim is rejected due to lack of a referral, verify that the primary care provider submitted the referral, and resubmit the claim within the timely filing limit.
For any extension of the following services, providers must have an active referral or written orders from the referring physician for care:
- Physical therapy
- Occupational therapy
- Home health care
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.
In addition, the following outpatient services don't require a referral when provided by an in-network provider:
- Routine hearing exams
- Nutritional counseling
- Routine vision exams. Most HMO members now have coverage for one routine vision exam every 24 months. However, some groups opt to modify these guidelines, so be sure to verify the members’ benefits before rendering care. (Medical eye care visits do not have the 24-month limit.)
- The following specialty-care services provided by a plan obstetrician, gynecologist, certified nurse midwife or family practitioner:
- Annual preventive gynecological exam (including any subsequent medically necessary OB/Gyn services). Please note: Medicare Advantage members require a referral for medically necessary OB/Gyn services.
- Maternity care
- Medically necessary evaluations and resulting health care services for acute or emergency gynecological conditions.
- Certain durable medical equipment, including apnea monitors and oxygen. Specific durable medical equipment items require medical policy review; for example, wound vacs and specialty beds. Please check benefits and eligibility before providing services to determine member’s cost share and durable medical equipment limits, if any.
- Initial home health care visit for early maternity discharges
- Outpatient hospice services, including home health aide visits, drugs, durable medical equipment, skilled nursing visits, respite care and bereavement services. However, authorization is required for any home infusion therapy services provided as part of hospice care. For Medicare Advantage (Medicare HMO Blue and Medicare PPO Blue) members, hospice services are covered under the member’s Medicare benefit.
- Applies only to commercial members who have acupuncture benefits. These benefits are being phased in during 2020 as the employer renews their health plan coverage. To confirm the benefits, perform an eligibility inquiry for ‘acupuncture’ services and verify the plan renewal date.