Referrals, Prior Authorizations, and Care Management

Referrals, Prior Authorizations, and Care Management

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An Independent Licensee of the Blue Cross Blue Shield Association

044506 (11-30-2021)

Referrals

Medicare Advantage referrals

? The primary care provider (PCP) is responsible for making sure the referral is submitted and approved.

? The PCP must fill out and submit the referral request online or by fax for all services performed by a specialist.

? Fully complete the form, otherwise, a new referral form will need to be completed and submitted.

? As a courtesy, providers can submit referrals with a retroactive date, no greater than 60 days after the date of care.

? Make sure you're referring patients to in-network providers. Our MA members don't have out-of-network benefits unless it's emergency care.

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Medicare Advantage referrals

Referrals from PCPs are only required for services from specialists outside a primary care provider's health system.

Types of services that don't require a referral.

Emergency room services Routine vaccinations Routine hearing exams Routine acupuncture services

PT, SP, and OT Services

Routine women's healthcare

Routine and Medicare-covered vision exams

Routine naturopathic services

Routine and Medicare-covered chiropractic services Routine and Medicare-covered podiatry services

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Medicare Advantage referral submission

? Referrals can be submitted online by clicking on the "Sign in to tool and resources" link on this page.

? Alternatively, referrals can be submitted by fax. ? Completed referral forms can be faxed to 866-809-1370. ? Referral submission forms are available online on our Medicare Advantage website under forms: wa/provider/medicare-advantage.

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