The AmeriHealth Direct Point-of-Service (POS) benefits plan allows members to
see most providers
without a referral. AmeriHealth Direct POS requires
primary care physician (PCP) referrals only for routine radiology,
physical/occupational therapy, and spinal manipulations. Obtaining a referral
for these services ensures that the member receives the highest level of
benefits.
For laboratory services, AmeriHealth Direct POS members must obtain a
laboratory requisition form from their PCP or specialist. These members will be
directed to their designated (capitated) laboratory site for laboratory
services. For all other services, members may visit any AmeriHealth network
provider, without a referral. Using providers in the AmeriHealth network gives
AmeriHealth Direct POS members the highest level of benefits and the lowest
out-of-pocket costs.
The AmeriHealth capitation program remains in effect for AmeriHealth Direct
POS. Similar to our AmeriHealth HMO and POS benefits, PCPs must refer
AmeriHealth Direct POS members to capitated providers for capitated services
(i.e., radiology, physical/occupational therapy, laboratory) for members to
receive the highest level of benefits.
Note: For podiatry services, a referral has not been required since
January 1, 2013, when the capitation program for podiatry ended.
How the plan works
AmeriHealth Direct POS members select a participating PCP from the AmeriHealth
network.
No referrals are required for AmeriHealth Direct POS members to see
participating specialists.
Referrals are required for routine radiology, physical/ occupational therapy
services, and spinal manipulation.
A requisition form is required for laboratory services.
AmeriHealth Direct POS members are responsible for applicable cost-sharing.
AmeriHealth Direct POS members do not need to file claim forms when services
are provided by participating specialists.
Note: For services requiring precertification through AIM Specialty
Health
® (CT/CT scans, MRI/MRA, nuclear cardiology services, and
PET scans), a separate PCP referral is not required. Additionally, referrals
are never required for mammography.