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 parameters:

  • 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.
  • Exception: The following specialties do not require referrals when in-network (procedure codes listed in Exhibit 1):
    • Optometry
    • Mental:
      • Behavioral Health
      • Substance use disorder (SUD) providers
    • Gynecology
    • Routine maternity/obstetrics
    • Dental
    • Addiction medicine
    • Emergent or urgent services
    • Pediatric PCP Services
  • Maximum of three visits to specialist per PCP referral. After the third visit, the 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 July 20, 2022)".


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