Nevada referral management policy
All members on a product with referral management will have an attributed PCP within the product parameters:
- Nevada utilizes PMG designation for member attribution.
- Nevada uses PMG assignment, or member selection happens at the PMG level when there is a group practice in place.
Application for all products within:
- Guided Access HMO
- Pathway X Guided Access HMO
- Convenient Care HMO (launching January 2023)
- Referral orders must be created by the system attributed PCP of the member.
- Referrals must be limited to an in-network provider only. If PCP is seeking a referral for an
out-of-network (OON) provider, then all OON authorization processes must be followed.
- Specialist claims require a referral or will be denied, except as noted below.
- Exceptions: The following specialties do not require referrals when in-network (procedure codes listed in Exhibit 1):
- Behavioral health
- Substance use disorder (SUD) providers
- Addiction medicine
- Emergent or urgent services
- Pediatric PCP services
- Maximum of three visits to specialist per PCP referral. After the third visit, member must return to PCP to obtain a new referral. If a PCP believes additional referrals are required, then the PCP must contact Anthem Blue Cross and Blue Shield directly for a referral.
- All referrals expire in 90 days.
Please see the attached table titled Referral Exclusion List and Procedure Codes (Exhibit 1 – as of June 9, 2022).
August 2022 Anthem Provider News - Nevada