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: