Referral process for Primary Care Network

Within the Primary Care Network (PCN) program, the primary care physician (PCP) is the care manager, who is responsible for referring, authorizing, ordering, arranging and coordinating all health-care needs. The PCP should refer patients to participating providers (physician specialists, hospitals and other health-care professionals who have agreed to work with the PCN, group and PCP in delivering healthcare).

Networks

After discussion with the patient, the PCP decides when a specialist is needed and, with input from the patient, which specialist will be used. Participation may be in the Preferred Payment Plan (PPP), FirstSource PPO, a local physician-hospital organization (PHO), a contracting preferred provider organization (PPO) or other independent contracting providers. BlueAdvantage Administrators of Arkansas or the employer's group administrator sends the appropriate provider directories to PCN physicians for use in making referrals.

Referral Forms

When a PCP sends a patient to a specialty provider, the PCP must complete a referral form. Referral forms are not required for the following:

• Pathologists
• Radiologists
• Anesthesiologists
• Normal newborn services
• Services rendered by a PCP backup physician
• Durable medical equipment
• Ambulance services

A new BlueAdvantage PCN Script Pad Referral Process went into effect in 2001. The Script Pad Referral Process provides an authorization process for a participating PCP to refer a member to a provider for services outside the PCP's office.

You may download a Referral Form [pdf] here. This file will allow you to print a copy for completing offline.

Referral Authorization Process

1. The member's PCP or the PCP's approved covering (backup) physician is required to authorize services performed outside the PCP's office prior to the delivery of services.
2. The member is responsible for obtaining a Referral Authorization from the PCP prior to receiving services.
3. The referral form should be filled out completely by the PCP and given to the member as verification that the PCP has authorized services.

   The following information must be included on the Referral Authorization Form:

   • Member name and ID number
   • Provider name
   • Diagnosis
   • Reason for referral
   • Any restrictions
   • Date span of services
   • Number of visits
   • PCP name
   • PCP's five-digit Arkansas Blue Cross and Blue Shield/BlueAdvantage provider number
4. The PCP should place a copy of the referral in the member's medical chart or maintain a written record of the referral for future reference.
5. The member should present this referral form when making the first provider visit.
6. Billing information:
   • When covered services are rendered in accordance with the current referral form, services provided by the participating provider do not need additional referrals.
   • If the specialist determines that another specialist needs to examine or treat the member, the PCP must be consulted. Referrals are accepted only from the PCP or an approved covering (backup) physician.
   • Referral services are subject to member eligibility and the benefits available through the member's plan. Therefore, a referral authorized by a PCP should not be considered as a guarantee of payment.
   • Specialty, hospital and ancillary providers need to enter the PCP's five-digit Arkansas Blue Cross and Blue Shield provider number in Field 23 on the CMS-1500 claim form (formerly HCFA-1500). This number notifies BlueAdvantage that the patient has not self-referred.

To obtain additional referral forms, the physician should call the customer service number on the member's ID card.

Out-of-Network Referrals

Referrals to out-of-network (OON) providers require prior notification to BlueAdvantage. Prior notification can be obtained by faxing the Script Pad Referral Authorization Form to BlueAdvantage at 501-378-2965 or by writing:

BlueAdvantage Administrators of Arkansas
P.O. Box 1460
Little Rock, AR 72203

Please note the following:

1. OON referrals must be made in advance of services rendered.
2. OON referrals must be requested by the member's PCP or an approved covering (backup) physician.
3. Emergency care does not require a referral.
4. Follow-up care does require a referral if not provided by the PCP.
5. OON referrals should be made by faxing a copy of the Script Pad Referral Authorization Form to BlueAdvantage at 501-378-2965. In addition, a copy of the Script Pad Referral Authorization Form should be provided to the member as verification that the PCP has authorized the services.
6. Services referred to and provided by an OON provider may not be eligible for reimbursement or may be covered at a reduced benefit level.

All referrals expire at the end of three months unless otherwise specified by the PCP, and the PCP will need to evaluate the need for continued referral. Services beyond those initially requested by the PCP may not be eligible for reimbursement unless authorized in advance.

Self-Referrals

Under most plans, self-referrals by patients will either be non-covered, or the payment to the specialist will be reduced significantly based on the benefit plan of the group. Some plans authorize self-referrals, which are eligible for coverage.