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Reminder: Referral procedures for capitated services

October 31, 2016

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There are a number of outpatient services included in designated (capitated) programs for commercial HMO and POS members. These services are:

  • diagnostic radiology*
  • short-term rehabilitation*
  • laboratory
Primary care physicians (PCP) must refer members to their capitated site for these specialty services. In addition, participating specialists must refer HMO and POS members to the capitated sites of the member's PCP. The member's capitated laboratory site is indicated on his/her member ID card. You may obtain additional specialty site information for the member's PCP on the NaviNet® web portal by using the Eligibility and Benefits Inquiry transaction.

For more information regarding member referrals to capitated sites, please refer to the Specialty Programs section of the Provider Manual for Participating Professional Providers.

If you have any questions, please contact your Network Coordinator.

* Radiology and physical therapy services are not capitated for Keystone 65 Focus Rx HMO (Keystone 65 Focus) members. These members must be directed to a participating provider in the Keystone 65 Focus network. Referral requirements still apply

NaviNet is a registered trademark of NaviNet, Inc., an independent company.

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