Referral process

Health Advantage members with an HMO or point-of-service (POS) policy must choose a primary-care physician (PCP) to coordinate their medical care. When needed, the PCP will refer the member to an appropriate in-network specialist.

Members with an open access policy may or may not choose a PCP. It is not mandatory, but it is encouraged. Referrals are not required with an open access plan. (Your member ID card will indicate if your plan is "open access.")

Written authorization

For referrals, PCPs use the "script" method. The PCP may give the patient a written authorization form to be taken to the appointment with the in-network specialist or fax the form to the in-network specialist. The in-network specialist or in-network facility then uses the referral number when filing the claim with Health Advantage.

Members are responsible for obtaining the referral prior to receiving services from a specialty provider. Failure to obtain the referral prior to services will result in the claims either being denied or going toward the lower level of benefits depending on the member’s medical plan.

For a referral to a specialist not participating with Health Advantage (out-of-network), the member's PCP must submit an out-of-network referral request to Health Advantage for possible coverage authorization. If the member is on an open access policy and does not have a PCP assigned, Health Advantage will accept an out-of-network referral request from another participating provider who has seen the member for the same medical condition currently being treated. There are very few, if any, specialty services that are not available from an in-network specialist.

Note that retroactive referrals are discouraged and may not be authorized for coverage.

Exceptions:

• Women do not need a referral from a PCP or Health Advantage for annual obstetrical/gynecological (Ob/Gyn) checkups, as long as members visit an in-network physician.
• Plans with routine eye-care benefits will not need a referral for that visit as long as the ophthalmologist or optometrist is a participating provider.
• Emergency care and urgent care do not require referrals. Refer to your Evidence of Coverage for definitions of emergency care and urgent care and any procedures you need to follow.