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 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)".

NVBCBS-CM-004821-22