Frequently Asked Questions (FAQs) for Referral Process
Prior Authorization or pre-certification - An approval required prior to a member receiving a service or procedure and is subject to a medical necessity review.
Referral – An approval required prior to a member’s office visit to see a specific in-network specialty provider. It is not subject to medical necessity review.
- Effective April 1, 2018, members are required to have an active referral on file prior to an office visit for an in-network specialist associated with the following specialty types:
- Orthopedic Surgery
- Referrals should be submitted by a member’s Primary Care Physician (PCP) prior to the member’s visit with one of the above specialty types.
- PCPs can submit a referral via the Provider Portal, fax or calling the Centralized Medicare Unit (CMU)
- A member’s referral is active for one (1) calendar year from the date of submission and covers unlimited office visits related to the specialty type indicated on the referral.
Referrals can be submitted by an in-network PCP one of three ways:
Submit a Referral via Provider Portal
- Log onto the Provider Portal and verify member’s eligibility,
- Navigate to “Authorizations” button,
- Select “Create a New Authorization,”
- Under “Provider Request” tab, select the “Referral” service type under Medical Outpatient from the menu
- Fill in Primary Care Physician’s information and insert primary diagnosis then click “Next”
- Under “Service Line,” tab fill in servicing provider’s information and click “select”
- Servicing providers can be searched for by last name or NPI, click on tab to initiate search.
- When selecting the servicing provider, remember non-PAR providers cannot be selected.
- Complete remaining fields and proceed with submitting referral.
Submit a Referral via Fax
- Use Fax Referral Form located on the health plan’s provider website
- Fill in all required fields accurately to ensure approval upon first submission
- Fax form to fax number listed at the top of the referral form
Submit a Referral via Phone
- Make sure you have the following information prior to call: your provider’s NPI, diagnosis, name or NPI of provider to whom you would like to refer the member,
- Call the Centralized Medicare Unit (CMU) at 855-565-9519
- Select “provider” then “referral” prompts.
- Press “3” for providers then press “4” for referral
- Provide requested information to referral specialist
The patient’s PCP is the only personnel authorized to submit a referral. (Referrals are only required for: cardiology, gastroenterology, orthopedic surgery, dermatology and rheumatology).
No. Only the assigned PCP can refer a member to a specialist.
Referrals will cover the office visit and any subsequent treatment that does not require prior authorization. The servicing provider should reference the Medicare Prior Authorization Tool to see if the procedure requires prior authorization. If the procedure does not require prior authorization, no further approval is necessary. If the procedure does require prior authorization, the provider must submit a prior authorization request prior to delivering service.
We encourage all providers to stay within network when coordinating care for a member. If a member requires service from an out-of-network specialist, a prior authorization is required; no referral is needed.
- Via Provider Portal – auto approved; accepted 24-hours (recommended)
- Via Phone – auto approved; accepted only during business hours
- Via Fax – allow up to 72-hours; PCP will only receive fax-back if information is incorrect
Once a referral has been submitted and approved, it is valid for one (1) calendar year from the date of the PCP’s submission.
Yes. A member can have multiple active referrals, only one (1) referral per specialty type is required.
No, as long as a referral is on file, your claim will process correctly. Nothing different needs to be done or noted on the claim form.
In order for the plan to pay the claim there must be an active referral on file. If there is not an active referral you must contact the assigned primary care provider (PCP) and have him/her submit a referral. A claim will not be paid without an active referral.
You can log onto the provider portal to check if there is an active referral on file for your patient.
If you cannot locate a specialist on the provider portal, that specialist may be out of network. Referrals can only be made to in-network-specialists and the portal will not allow you to submit a request to an out of network provider. Sending a member to an out-of-network specialist requires a prior authorization and is subject to a medical necessity review.
As long as you have the correct provider NPI and diagnosis code, submitting a referral should take less than two minutes.
Provider Portal - If you are submitting a referral via the portal, you will receive a referral confirmation number on the screen after the referral has been submitted.
Phone – If you are submitting a referral via phone, the referral specialist will provide you with the referral confirmation number.
Fax – If you are submitting a referral via fax, the processing time is ~72 hours. The status of your referral can be checked using the provider portal.