Effective October 1, 2020, new BlueCare Prime HMO plans will become available to the State of Connecticut Employer Group, and on January 1, 2021 for individuals and small groups in Connecticut.  These plans will require PCP referrals for specialized care. Following is important information regarding the referral process and requirements for BlueCare Prime HMO members. 

 

If a primary care physician (PCP) determines that a member needs specialized care, he or she will authorize the member to receive health care services from another health care provider. A referral for specialized care is not a guarantee of coverage for those services; the service must also be covered within the terms of this Subscriber Agreement. Thus, regardless of medical necessity, no benefits will be provided for care that is not a covered service, even if performed by a PCP or by another provider under a referral authorized by a PCP. Providers may call the Provider Call Center to determine if a service is a covered service.

 

  • If a PCP authorizes a referral to another provider, the PCP must ensure the member understands:
    • The name of the provider to whom they are being referred
    • The period of time, the number of visits and services for which care is authorized
    • Who will schedule appointment(s) with that provider – member or PCP’s office staff
  • The referred provider should consult with the member’s PCP if the care exceeds the initial referral for services.
  • If the referred provider recommends a member to another provider, the referred provider must contact the PCP prior to any treatment so he or she can determine if that care will be authorized. Only a PCP can authorize care with another provider.
  • If the PCP authorizes these services, benefits will be provided according to the terms of the member’s Subscriber Agreement. Care that is not authorized by a PCP is not covered, unless the member’s Plan allows for coverage at a self-referred or out-of-network level. Providers may call the Provider Call Center to determine member benefits and if a service is a covered service.
  • PCPs must use the Optum referral tool to generate referral authorizations to in-network specialists, unless another referral tool is agreed upon by Optum under the managed program.
  • PCPs may issue members a copy of their referral. Members should retain this information as a confirmation of the PCP referral to see a specialist or provider who specializes in treating their specific illness or injury.
  • While most services will require a referral some services do not, such services include but are not limited to:
    • Services from the member’s PCP
    • Online visits
    • Routine obstetrical and gynecological (ObGyn) including maternity services
    • Mental health and substance abuse services
    • Diagnostic x-rays
    • Diagnostic labs at an independent lab
    • Routine eye exams
    • Medical emergency conditions
    • Walk-in centers
    • Retail health clinics
  • Providers may call the Provider Call Center to determine member benefits and to confirm when a referral is required. Referrals do not take the place of prior authorizations. Prior authorizations will need to be obtained when mandated by the benefit plan.
  • Note: If a PCP determines a member does not need a referral and the member disagrees, the member has the right to appeal the decision. The member’s Subscriber Agreement outlines the necessary steps in submitting an appeal.

 

Referrals to in-network specialists

PCPs may refer members to in-network specialists. Referrals to in-network specialists are required for HMO gatekeeper plans. Specialists may use an approved referral for derivative services (e.g. laboratory, radiology, inpatient admission) related to that episode of care. Please refer to the Optum training manual for further information with respect to approved referrals for Blue Care Prime members.

 

Referral to non-network providers

At times, a member may require services that are not available from providers within the network. A PCP may make a referral to an out-of-network provider. Referrals to an out-of-network provider must be pre-approved by Anthem for services to be reimbursed.

 

Standing referrals

A member with a special condition requiring ongoing care from a specialist may receive a standing referral to a specialist for treatment of the special condition from the member’s PCP. A special condition is a condition or disease that is life-threatening, degenerative, or disabling and requires specialized medical care over a prolonged period of time. A standing referral must be made according to a treatment plan, approved by our Medical Director in consultation with the member’s PCP.

 

Claims submission

  • Professional providers must place the BlueCare Prime referral number in Box 23 of the CMS 1500 form - Loop 2300 REF01/02 with 9F Qualifier - Referral Number or G1 Qualifier - Prior Auth
    • Note: All other Anthem HMO plans’ professional providers must continue to place the PCP NPI number in Box 17 B of the CMS 1500 form.
  • Facilities must place the BlueCare Prime referral number in Box 63 B of the UB04 form - Loop 2300 REF01/02 - 9F Qualifier - Referral Number or G1 Qualifier - Prior Auth

 

If the referral number is not present on the claim, and depending on the type of plan, benefits may be non-covered, or processed with deductible and coinsurance.  Please check member’s benefits by using Availity or by contacting the Provider Call Center.

 

BlueCare Prime member ID number prefixes:

State of Connecticut Employer Group (effective October 1, 2020)

X6G

 State BlueCare Prime HMO (PCP referral required)

HMO-POS

Please see article titled ‘Important State of Connecticut Employer Group, State Partnership Plan changes’, for more information about benefit changes and ID number prefixes for those members.

 

Individual Market (plans available beginning January 1, 2021)

Z9T

BlueCare Prime HMO (PCP referral required)

HMO-POE

X6T

BlueCare Prime HMO (PCP referral required)

HMO-POE

 

Small Group Market (plans available beginning January 1, 2021)

C9T

BlueCare Prime HMO (PCP referral required)

HMO-POE


616-0920-PN-CT

 



Featured In:
September 2020 Anthem Connecticut Provider News