Understanding the referral system
Your primary care physician works with you and BCN to arrange the specialty care you need. Here’s how the triangle of care works:
How do I receive specialty care?
Schedule a visit with your primary care physician, who will evaluate your health concerns. If you want to see a particular specialist, discuss it with your PCP. If your PCP decides that you should see a specialist, he or she will write a referral to cover a period from 30 days to 365 days. You are responsible for the charges if you receive specialty care without a referral. If you and your PCP are unable to agree about specialty care, please call us.
Can my specialist refer me to another specialist?
No, a specialist cannot refer you to another specialist. If the specialist recommends that you see another specialist, he or she will contact your PCP.
What services can my specialist provide?
Your specialist may order any medically necessary service up until the expiration date of the referral from your PCP. Some services require review by Blue Care Network.
What types of referrals require review by BCN?
BCN's clinical staff reviews the appropriateness of some services before they are provided. These are examples of services that require prior review:
- Procedures that may be potentially cosmetic such as removing excess scar tissue from your eyes or abdomen
- Physical therapy, speech therapy, and occupational therapy
- Gastric bypass for weight reduction
- Bone marrow transplant
- Infertility services
- Breast reduction
- Durable medical equipment
- Services provided by out-of-network physicians or providers
- Procedures that may be experimental or investigational
Do I have out-of-network coverage?
Check with your PCP before receiving any out-of-network medical care unless it is an emergency. You must have a referral from your PCP before you get care from providers who are not part of our network, and BCN must authorize the service. If you receive medical care from a physician or other provider who is not part of our network without a referral from your PCP and approval from BCN, you will be responsible for the cost of the service.
How will I know if my referral is approved by BCN?
BCN will send you written notification of approval in the mail, or your doctor will tell you.
What do I do if I change my PCP while receiving care from a specialist?
If you change your PCP while a specialist is treating you, your new PCP must reauthorize the treatment you are receiving. Your treatment may not be covered until that occurs.
Do I need a referral to see an OB-GYN?
No, refer to our Woman's Choice program for details.
What if I have a question about a specific referral case or issue?
page modified 09/23/2011