This is a reminder that commercial HMO and POS and Medicare Advantage HMO (HMO/POS) members are required to have a referral for specialty care, including for non-emergency and hospital care. The referral must be issued by the member?s primary care physician (PCP) through the NaviNet^® web portal. If an HMO/POS claim is received for specialty services and a referral is not on file, the claim will be denied for ?no referral.? Referrals are valid for 90 days and do not guarantee active eligibility on the date of service. PCPs should be as specific as possible when issuing a referral. Members who are not eligible on the date of service will be responsible for payment. All visits must occur within the 90-day period following the date the referral is issued. Non-emergency services (other than Direct Access services, which include OB/GYN, infertility, and maternal fetal medicine) that have not been referred by the PCP will not be covered. HMO members must be referred to participating providers only. If a participating provider cannot provide care, and a referral to a nonparticipating provider is contemplated, such a referral by a PCP requires AmeriHealth preapproval.

For Pennsylvania and Delaware members

• For HMO/POS members, all radiology referrals must be to the PCP?s capitated site.
• For HMO/POS members in Pennsylvania, all outpatient laboratory and short-term rehabilitation referrals must be to thePCP?s capitated site.
• For HMO/POS members in Delaware, a referral is not required for short-term rehabilitation or outpatient laboratory services.
• For Direct POS members, no referrals are required for members to see participating specialists. However, referrals are required for routine radiology (except mammograms), spinal manipulation, and physical/occupational therapy services. To receive the highest level of benefits, members should be referred to the PCP?s capitated site for capitated services (i.e., radiology, physical/occupational therapy, and laboratory).

For New Jersey members

• For HMO/POS members, all outpatient laboratory and short-term rehabilitation referrals must be referred to the PCP?s capitated site.
• For AmeriHealth New Jersey members in southern New Jersey*, all radiology referrals should be made to the PCP?s capitated site.
• Should an HMO/POS member choose to receive services you have authorized from a participating provider other than the PCP?s capitated site, the PCP must issue a referral to any participating provider. Preapproval is not required.
Members enrolled in ?Plus? and EPO products are exempt from all referral requirements.
• PCPs in the AmeriHealth New Jersey Value Network should only issue referrals to specialists who are participating in the AmeriHealth New Jersey Value Network. A list of participating providers can be found online by using the Provider Finder tool.

For additional information regarding referral requirements, please review the Administrative Procedures section of the appropriate Provider Manual for Participating Professional Providers, which is available on AmeriHealth NaviNet Plan Central in the Current Publications section.

*Counties that represent southern New Jersey are: Atlantic, Burlington, Camden, Cape May, Cumberland, Gloucester, Mercer, Salem, and Ocean.

NaviNet^® is a registered trademark of NaviNet, Inc.