As outlined in the Hospital Manual for Participating Hospitals, Ancillary
Facilities, and Ancillary Providers and the Provider Manual for
Participating Professional Providers, when referring an AmeriHealth member
for a surgical procedure or hospital admission, the primary care physician
needs to issue only one referral to the specialist or
attending/admitting physician.
Please note the following:
- The referral will cover all facility-based (i.e., hospital, ambulatory
surgical center) services provided by the specialist or attending/admitting
physician for the treatment of the member?s condition.
- The referral is valid for 90 days from the date it was issued.
- The admitting physician should obtain any required preapproval.
- Any pre-admission testing and hospital-based physician services (e.g.,
anesthesia) will be included under the hospital or surgical preapproval.
Please ensure the referral, when required, is on file to the specialist or
attending/admitting physician prior to rendering the surgical/outpatient
procedure or other outpatient service or your facility-based portion of the
claim may be denied for lack of referral.
Certain products (e.g., HMO, POS, PPO) have specialized referral and
preapproval requirements and/or benefits exemptions. It is important for
providers to utilize the most current precertification requirement lists for AmeriHealth New Jersey and AmeriHealth
Pennsylvania. Failure to obtain precertification for any of the services
that require precertification may result in a reduction in payment or
nonpayment for services provided.