Primary Care Coordinator Plans (PCC Plans) do not require a referral.
An out-of-network (OON) referral means a written authorization provided by a participating care provider and approved by us for services to be received from a non-participating care provider. OON referrals must be requested by the member’s PCP. If an OON referral is obtained, services received from a non-participating care provider are covered at a network level of benefits under the member’s benefit plan. An OON referral is needed when services are not available from a participating care provider and may be needed for various services including, but not limited to, podiatry, chiropractic and mental health/ substance use services.
Out-of-Network Referral Approval
A referral to an OON care provider must be approved by us before the services are rendered. We must also give prior approval for modified or expired OON referrals as described in this supplement. We may approve an OON referral when services are needed but not available from a participating care provider. Prior approval of an OON referral is required for each follow-up visit unless we indicate otherwise. A medical director will review requests that do not meet approval criteria.
In the case of emergencies, notify us the first business day following the referral.
Out-of-Network Referral Process
To determine whether an OON referral is necessary under a member’s benefit plan, contact us at the number on the back of the member’s health care ID card.
Refer to the section Non-Participating Care Provider Referrals (All Commercial Plans), in Chapter 5: Referrals, for more instructions.
- We will make decisions within the time frames required by state and federal law (including ERISA) and in accordance with NCQA standards.
- We will send a letter confirming our approval or denial of a referral to the member and your office.
If a member requests approval after the fact, advise them this is against policy. Ask them to call 877-842-3210.
Participating care providers may not refer their own family members to non-participating physicians/facilities due to conflict of interest. If the care provider denies a referral, the care provider must refer the member to their benefit document for any appeal rights. Or have them call 877-842-3210.