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).
Specialists:
For any extension of the following services, providers must have an active referral or written orders from the referring physician for 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: