Reminder: refer Medicare Advantage members to in-network providers
As a reminder, PCPs may only refer Anthem members to in-network Medicare Advantage providers.
We have contracted with specialists to ensure adequate care of our members. The use of contracted network specialists will ensure continuity of appropriate clinical background data and coordination of care with the PCP.
Should there be a need to refer the member outside the contracted network, contact Anthem directly for prior authorization (PA). Referring a Medicare Advantage member out-of-network, who does not have out-of-network benefits, could result in claim denials with member liability unless the service is urgent, emergent, out-of-area dialysis or if PA was approved by the plan.
Although not required, PA is encouraged for preferred provider organization (PPO) members who want to receive notification of advanced coverage when utilizing an out-of-network provider for services.
As a reminder to all providers, the referring physician name and NPI must be reported on the claim when the PCP does not provide the service rendered. This will help reduce the number of rejections issued during initial claim processing.
December 2019 Anthem Maine Provider News