Do I Need a Referral to See a Specialist With Blue Cross Blue Shield Ppo

April 2019

BCBSTX Plans and Referral Requirements

Blue Cross and Blue Shield of Texas (BCBSTX) has the following PPO and HMO plans:

Blue Choice PPO SM
Covered members have direct access to all in-network Blue Choice PPO providers. A covered person does not need to obtain a referral from their primary care physician (PCP) to seek services/care from an in-network specialty care physician or provider. Covered persons can choose to use out-of-network providers under their out-of-network benefit. If an out-of-network provider, including facilities, are necessary due to network inadequacy or continuity of care, then authorization is required by BCBSTX.

HMO Plans

  • Blue Advantage HMOSM
  • Blue Advantage PlusSM*
  • Blue EssentialsSM
  • Blue Essentials AccessSM*
  • Blue PremierSM
  • Blue Premier AccessSM*

Blue Advantage HMO, Blue Essentials and Blue Premier require referrals initiated by the covered person's designated PCP and must be made to an in-network physician or professional provider in the covered person's applicable HMO provider network. Blue Essentials, Blue Advantage HMO and Blue Premier physicians and professional providers are required to admit a patient to an in-network facility in the covered person's HMO provider network, except in an emergency.

*Note:

  • Blue Essentials Access and Blue Premier Access are considered "open access" HMO plans where no PCP selection or referrals are required when the covered person uses in-network providers in their applicable HMO network.
  • Blue Advantage Plus allows covered persons to use out-of-network providers. Covered persons can choose to self-direct their care under their out-of-network benefit at a higher out-of-pocket cost. Please be sure the covered person understands the financial impact of receiving services from an out-of-network provider, including facilities.

The table below defines when PCP selection and referrals to specialists are required and if out-of-network benefits are available for the HMO plans.

  • Exception: No referrals are required for in-network OB/GYNs in the covered person's applicable HMO network.
  • When in-network providers and/or facilities are not available in the covered person's applicable HMO network, preauthorization would be required to utilize an out-of-network provider and/or facility.

HMO Plan

Designated PCP Required

Referrals Required for In-Network Providers

Out-Of-Network Benefits Available with Higher Covered Person's Cost Share

Blue Advantage HMO

Yes

Yes

No

Blue Advantage Plus**

Yes

Yes

Yes

Blue Essentials

Yes

Yes

No

Blue Essentials Access

No

No

No

Blue Premier

Yes

Yes

No

Blue Premier Access

No

No

No

**Before referring Blue Advantage Plus covered persons to an out-of-network provider for non-emergency services, please refer to the Section D Referral Notification Program of the Blue Essentials, Blue Advantage HMO and Blue Premier Provider Manual for more detail (including when to utilize the Out-of-Network Enrollee Notification forms for Regulated Business and Non-regulated Business).

Reminders:
  • Some services in both HMO and PPO plans may require preauthorization or prenotification.
  • It is imperative that providers use Availity® leaving_site Icon or their preferred vendor to obtain eligibility and benefits, determine if you are in- or out-of-network for their plan, and whether preauthorization/prenotification is required. Availity allows preauthorization determination by procedure code. Refer to the BCBSTX Eligibility and Benefits web page for more information on Availity.
  • Utilize iExchange® or call the preauthorization number on the back of the covered person's identification (ID) card to obtain authorization.
  • Sample ID cards are available on the BCBSTX provider website.

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Source: http://www.bcbstxcommunications.com/newsletters/br/2019/may/nlt_br_providers_may_2019_referral_requirements.html

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