As outlined in the Hospital Manual for Participating Hospitals, Ancillary Facilities, and Ancillary Providers and the Provider Manual for Participating Professional Providers, when referring an AmeriHealth member for a surgical procedure or hospital admission, the primary care physician needs to issue only one referral to the specialist or attending/admitting physician.

Please note the following:

• The referral will cover all facility-based (i.e., hospital, ambulatory surgical center) services provided by the specialist or attending/admitting physician for the treatment of the member?s condition.
• The referral is valid for 90 days from the date it was issued.
• The admitting physician should obtain any required preapproval.
• Any pre-admission testing and hospital-based physician services (e.g., anesthesia) will be included under the hospital or surgical preapproval.

Please ensure the referral, when required, is on file to the specialist or attending/admitting physician prior to rendering the surgical/outpatient procedure or other outpatient service or your facility-based portion of the claim may be denied for lack of referral.

Certain products (e.g., HMO, POS, PPO) have specialized referral and preapproval requirements and/or benefits exemptions. It is important for providers to utilize the most current precertification requirement lists for AmeriHealth New Jersey and AmeriHealth Pennsylvania. Failure to obtain precertification for any of the services that require precertification may result in a reduction in payment or nonpayment for services provided.