Submitting and Verifying Referrals
A PCP or OB/GYN may issue a referral to participating care providers using any of the methods outlined in the “How to Contact Oxford Commercial” section.
Once you enter the referral, the referring care provider may receive a reference number by fax. Provide the referral reference number to the member. The member may bring this reference number to the specialist who can directly confirm a referral is on file through OxfordHealth.com or by phone.
Referral Policies and Guidelines
Our physician contracts require referrals be issued to participating physicians, hospitals, ancillaries and other health care professionals within the applicable network of care providers available to our members enrolled in gated health benefit plans. The only exceptions to this are:
- Cases of emergency, or
- There are no participating care provider who can treat the member’s condition.
If you would like to direct a member to non-participating care providers, you must request a network exception from our Clinical Services department and receive approval before the member receives service.
If the member requests to see a specialist and is unable to reach their PCP or OB/GYN (after-hours, weekends or holidays), the PCP may issue a referral up to 72 hours after the member received services.
Precertification guidelines still apply to those covered services requiring precertification.
We must review and approve all referrals. A referral does not guarantee coverage of the services provided by the participating specialist. Covered services are subject to:
- Medical necessity, as determined by Oxford’s Clinical Policies
- Member eligibility on the date(s) of service
- Member’s benefits as defined in the conditions, terms and limitations of their Summary of Benefits/Certificates/Contract
Participating specialists can only issue referrals within the applicable network of care providers available to the members enrolled in gated health benefit plans for certain covered services as outlined in the Referral Policy referenced above. You may not refer a member to a nonparticipating specialist.
For more information refer to the section on Using Non-Participating Health Care Providers or Facilities.
Automated Fax Notification
When you submit a referral, we send a fax to the referred-to-care provider or other health care professional, usually within 24 hours. This fax serves as a confirmation notice of the referral.
Care providers have the option to update their referral fax number or decline the auto-fax notification feature on our website in the My Account section.
We have created a number of programs to improve outcomes for members and help us better manage the use of medical services. Care providers may refer members to these programs, or members may self-refer, to network specialists for the following services:
- OB-GYN care, to include prenatal care, two routine visits per year and any follow-up care, or for care related to an acute gynecological condition
- One mental health visit and one substance use visit with a participating care provider per year for evaluation
- Vision services from a participating care provider
- Diagnosis and treatment of Tuberculosis by public health agency facilities
- Family planning and reproductive health from participating or Medicaid care providers
Outpatient Radiology Self-Referral Procedures
We designed the outpatient imaging self-referral policy to promote appropriate use of diagnostic imaging by network PCPs, specialty physicians and other health care professionals in the office and outpatient setting.
This policy does not apply to radiology services performed during an inpatient stay, ambulatory surgery, emergency room visit, or pre-operative/pre-admission testing. See the How to Contact Oxford Commercial section for contact information.
The outpatient imaging self-referral list is applicable to commercial benefit plans (excluding Oxford USA Plans). You can find more information on OxfordHealth.com > Providers (or Facilities) > Tools and Resources > Medical Information > Radiology & Radiation Therapy Information > Oxford’s Outpatient Imaging Self-Referral Policy.
Standing Referrals and Specialty Care Centers
You may request a standing referral to a participating specialist, ancillary provider, or specialty care center if a member requires ongoing specialist treatment, has a lifethreatening condition or disease, or a degenerative and disabling condition or disease. This referral is available only if the condition or disease requires specialized medical care over a prolonged period.
The participating specialist or ancillary provider must have the necessary medical expertise and be properly accredited or designated (as required by state or federal law or a voluntary national health organization) to provide the medically necessary care required for the treatment of the condition or disease. We cover the services provided only to the extent outlined in the member’s Certificate of Coverage.