Referral Process
BeHealthy America allows beneficiaries to go to a participating specialist
without a referral from a PCP; however, the plan has a strong belief in the
value of the Patient-Centered Medical Home model and encourages
members to seek advice from their PCP prior to self-referring to a specialist.
Primary Care Physicians are not required, but are encouraged to provide a
referral for a participating Specialist Physician office visit. This referral can
be sent via the plan’s Referral Form or the Physician Portal.
ATTENTION SPECIALISTS: With the exception of simple X-rays,
ultrasounds and CT Scans, all procedures beyond an office visit will need a
referral from the member’s PCP in order to be eligible for payment. Some
procedures may require Plan pre-certification or notification; the type of
referral given to you by the PCP will determine which provider(s) can obtain
the pre-certification. If no referral was obtained, the PCP will need to request
the pre-certification of all procedures.
Primary Care Physicians (PCP’s) may provide a referral for the following
services using the Plan Referral Form. If the on-line referral process is used,
copies will be automatically forwarded to the plan and the specialist via fax
or email. If the Referral Form is used, one copy of the form will be placed in
the member’s chart, one copy faxed to the Provider or Facility getting the
referral and one copy faxed to the plan. Please note, no referral number will
be provided on this form and the referral will not be returned to the PCP
office by the plan.
The Referral Process will permit the Primary Care Physician (PCP) to
order the following allowable services with Participating Providers:
Office Visits performed in place of service -11
The PCP may order a consult from any participating specialist with the
referral process. A referral is not required for the office visit, but is required
for all procedures (with the exception of simple diagnostic radiology
procedures). This includes the specialties of Pain Management, Oncology,
Plastic Surgery, etc. for the initial evaluation. These specialties and others
may require pre-certification for certain services done in their office beyond
the initial evaluation (see the pre-certification list).
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The PCP may refer to a specialist or ancillary provider for an office visit only,
an office visit and specific services, or an office visit and any treatment
performed in a place of service 11 that does not require pre-certification.
The PCP may refer to a specialist or ancillary provider for:
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An office visit only (referral not required)
An office visit and specific procedures/codes*, or
An office visit and any treatment performed in a place of service 11
that does not require pre-certification
*The specialist or ancillary facility will need to go back to the PCP for
additional referral, if additional procedures or treatments are needed beyond
those indicated on the referral.
Radiology Procedures performed at a participating free standing
radiology facility in place of service – 11
Simple X-rays, Ultrasounds and CT Scans can be ordered on a script by
either the member’s PCP or a participating specialist.
MRI’s and Nuclear Radiology should be done with a plan Referral Form or
through the on-line referral process. PCP’s should refer for the MRI and
Nuclear Radiology unless the Specialist was given a referral to “evaluate and
treat” in which case the specialist office or the PCP may complete the
referral for the MRI or Nuclear Radiology.
All PET scans, virtual endoscopies and pill endoscopies require precertification which should only be obtained through the member’s PCP.
All radiology services done in an out-patient hospital setting (POS 22) need
to be pre-certified. This request needs to come from the member PCP.
Durable Medical Equipment (DME) and Orthotics/Prosthetics
All DME and Orthotics/Prosthetics under $500 Medicare Allowable can be by
referral from the PCP or from the specialist that was given a referral for
“evaluation and treat” or evaluation and the specific DME or orthotics/
prosthetics that are being ordered.
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Physical, Occupational or Speech Therapies in place of service 11
All Physical, Occupational or Speech Therapy can be done by referral from
the participating PCP or treating specialist.
The following are excluded from the Referral Process and need to be sent to
the plan for pre-certification by the PCP:
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Rehab therapy performed in an out-patient hospital setting
Therapies done in a member’s home (Home Health Care)
Procedures performed in an Ambulatory Surgery Center (POS 24)
The PCP should initiate the referral to the ASC except in cases where the
specialist received an evaluation and treat referral. A common example
would be a PCP sending a member to a participating gastroenterologist for a
colonoscopy. If the PCP writes the Referral for “Evaluate and Treat,” or
“Evaluate and colonoscopy” the gastroenterologist can initiate the referral to
the ASC.
Please note, the following procedures done at an ASC do require plan precertification: blepharoplasty, septoplasty, reduction mammoplasty,
rhinoplasty, vein surgeries, podiatry surgeries, ocular surgeries, plastic
surgery procedures, TMJ joint treatment, surgery or splinting, and pain
management injections.
Specialists are not allowed to refer to other specialist physicians. All
referrals to the specialist physician will be done by the member’s
Primary Care Physician.
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