Home Administrative Billing & Reimbursement BlueCard® Health and Wellness Medical PEAR portal Pharmacy Products Quality Management

Referrals are required for specialty care for HMO/POS members

July 1, 2014

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 would require IBC?s preapproval. Please also note the following: For HMO/POS members. All radiology, outpatient laboratory, and short-term physical and occupational therapy referrals must be to the PCP?s capitated site. Note: Providers in Berks, Lancaster, Lehigh, and Northampton counties in Pennsylvania are not required to choose capitated radiology or short-term rehabilitation sites. For Direct POS members. No referrals are required for Direct POS 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., routine radiology, physical/occupational therapy, and laboratory). For additional information regarding referral requirements, please review the Administrative Procedures section of the Provider Manual for Participating Professional Providers, which is available on IBC NaviNet Plan Central in the Current Publications section.

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


This content was prepared for the Provider News Center and may not be reproduced in any way without the express written permission of Independence Blue Cross. Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association.
Connect with us     Facebook     Twitter     Flickr     YouTube     Walk the Talk    Independence Pinterest    Independence LinkedIn    Independence Instagram Site Map        Anti-Fraud        Privacy Policy        Legal        Disclaimer
© 2023 Independence Blue Cross.
Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.