Member In-Network Only Specialist Referral Form Amazon



In-Network Only Plan

Primary Care Provider (PCP) Referral to Specialist

The following services do not require a referral:

|Ancillary Services |Medical Suppliers |

|Anesthesiologist |Mental Health and Substance Abuse |

|Assistant Surgeon |Newborns (Within the first 31 days of birth) |

|Autism Spectrum Disorder (ABA) |OBGYN |

|Chiropractors |Ophthalmology and Optometry |

|Emergency Ambulance Services |Pathologist |

|Emergency and Urgent Care |Preventative Services |

|Independent Labs |Radiologist |

|Facility and Ambulatory Surgery Center |Transgender |

Instructions:

1. Complete the member section of the referral form.

2. Bring this cover sheet, referral form, and detailed instruction page to your primary care provider (PCP).

3. Request a copy of the completed referral form from your PCP for your records.

Your PCP must complete this form and submit it to Premera Blue Cross before services are provided by an in-network specialist. If Premera does not receive this completed form before services are received, the claim for the specialist’s services will be denied.

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For the Provider

If you are receiving this referral form, it means your patient has selected you as their primary care provider for their medical plan. This form can also be used by providers that do not require a referral and are listed in the notes above.

Instructions:

1. Complete the applicable provider section of the referral form.

2. Submit the completed form to Premera Blue Cross via one of the following options:

• Fax : Attn: Customer Service 888-617-0495

• Online:

• Select: I am a provider > Library> Forms> Miscellaneous> Amazon in-network only plan primary care provider (PCP) referral to specialist.

• Phone > Customer Service Represenative: 877-995-2696

3. Provide a copy of the completed referral form to your patient for their records.

You must submit the completed form before an in-network specialist provides services to the member. Premera will deny plan benefits if the services are delivered before Premera receives the completed form.

If no end date is specified in Section 1-B of the form, then this referral remains in effect for one year after the start date in Section 1-A. Standing referrals (no end date specified) require approval from Premera.

Receipt and acceptance of this referral form does not guarantee a benefit nor does it constitute a prior authorization. To find out if there is a prior authorization on file or to find out the status of a referral, call Premera Customer Service at 877-995-2696.

Form Instructions

Section 1

PCP provides information about member who will see specialist.

A. Date when referral is effective; specialist may start to provide services to this member on this date.

B. Date when referral to the specialist ends. If this field is left blank the referral will default to one year after the start date.

C. Yes or no: Do you want a standing referral for this specialist? This requires approval. Contact Customer Service for more information.

Section 2

PCP or provider covering for PCP supplies provider information.

A. Last name, first name, middle initial, and suffix (if one applies) of PCP. If a covering provider is making this referral, supply this information for the PCP.

B. Either tax identification number or social security number of PCP. (Mandatory)

C. National Provider Identification (NPI) number of PCP, if number exists. If this number is provided, claims will process more quickly. (Optional)

D. Physical address of PCP service location. No P.O. Box numbers in this field.

E. Address where PCP wants to get billing information. P.O. Box numbers OK.

F. Telephone number for PCP.

G. Email address for PCP. (Optional)

H. Last name, first name, middle initial, and suffix (if one applies) of provider covering for PCP.

I. Either tax identification number or Social Security number of covering provider.

J. National Provider Identification (NPI) number of covering provider, if number exists. If this number is provided, claims will process more quickly. (Optional)

K. Telephone number for covering provider.

L. Email address for covering provider. (Optional)

Section 3

PCP or covering provider supplies information about the specialist.

A. Last name, first name, middle initial, and suffix (if one applies) of referred specialist provider.

B. Either tax identification number or

Social Security number of referred specialist provider. (Mandatory)

C. National Provider Identification (NPI) number of referred specialist provider, if number exists. If this number is provided, claims will process more quickly. (Optional)

D. Physical address of referred specialist provider service location. No P.O. Box numbers in this field.

E. Billing address of referred specialist provider.

F. Telephone number of referred specialist provider.

G. Email address of referred specialist provider. (Optional)

Section 4

PCP or covering provider must read, sign, and date this section, then fax signed form to number at bottom of form.

Primary Care Provider Referral to Specialist

In-Network Only Plan

Members: Complete the below member information and bring this form to your PCP.

|Member name: Last |First |Middle initial |Suffix |Gender |

|      |      |  |      |M F |

|Member ID number (From the member ID card. For example: AMK 100000000 01) |Date of birth |

|AMK          |      |

|Member home address (no P.O. Box) |

|      |

|Member telephone number |Member email address (optional) |

|(   )     -      |      |

Providers: Complete the below sections and fax the form to 888-617-0495.

|Section 1: Treatment information for member |

|A. Referral start date       |B. Referral end date (If not dated, referral ends after |C. Standing referral request? |

| |one year)       |Yes No (requires approval) |

|Section 2: Referring Primary Care Provider information |

|A. Primary care provider (PCP) Name: Last |First |Middle initial |Suffix |

|      |      |  |      |

|B. PCP tax ID number or Social Security number* (mandatory) |C. PCP NPI number (optional) |

|    -    -      |      |

|D. PCP service location address (no P.O. Box) |

|      |

|E. PCP billing address |

|      |

|F. PCP telephone number |G. Email address (optional) |

|(   )     -      |      |

|Covering provider information (to be filled out when a provider covering for the PCP makes a referral) |

|H. Covering provider name: Last |First |Middle initial |Suffix |

|      |      |  |      |

|I. Covering provider tax ID number or Social Security number* (mandatory) |J. Covering provider NPI number (optional) |

|    -    -      |      |

|K. Covering provider telephone number |L. Covering provider email address (optional) |

|(   )     -      |      |

|Section 3: Specialist information |

|A. Specialist name: Last |First |Middle initial |Suffix |

|      |      |  |      |

|B. Specialist tax ID number or Social Security number* (mandatory) |C. Specialist NPI number (optional) |

|    -    -      |      |

|D. Specialist location address (no P.O. Box) |

|          |

|E. Specialist billing address |

|          |

|F. Specialist telephone number |G. Specialist email address (optional) |

|(   )     -      |           |

|Section 4: Signature of referring provider |

|I certify that all information I have provided in this application, including any attachments, is accurate and complete to the best of my knowledge. I |

|understand that any false statement or misrepresentation of the information I have provided on my referral request or attachments will be grounds for |

|rejection of claims arising from this referral. I also understand that receipt and acceptance of this referral form does not in any way indicate that any |

|services provided subsequent to this referral are assured of benefits coverage under this plan. Coverage of services information and confirmation of benefits|

|must be sought through the other normal channels available. |

|Referring provider signature |Signature date |

|X |      |

* Either TIN or SSN may be provided. However, billing statements must use the TIN or SSN provided on this form.

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