Under the AmeriHealth Provider Agreement (Agreement), for HMO and POS members, except in an emergency, providers are required to refer members only to participating providers for covered services. This includes, but is not limited to, ancillary services such as laboratory (i.e., members and/or their lab specimens) and radiology.

Reminder: Specialists should ensure a referral is on file before rendering services. Services obtained without a referral, when one is required, will not be covered by AmeriHealth.

If a participating provider is not available for referral or direction of the member, the ordering provider must obtain preapproval from AmeriHealth before referring/directing the member to a non-participating provider.

If a provider is referring a member to a non-participating provider or provides/requests non-covered services to or for a member, the provider must inform the member in advance, in writing, of the following:

• a list of the services to be provided;
• AmeriHealth will not pay for or be liable for the listed non-covered services;
• the member will be financially responsible for such services.

You can access the AmeriHealth Member Consent for Financial Responsibility for Unreferred/Non-covered Services Form on our website. By signing this form, the member agrees to pay for non-covered services specified on the form. The form must be completed and signed before services are provided.

If a member presents without a referral, the provider should request that the member completes a financial responsibility form.

Depending on your Agreement, if a provider does not comply with the requirements as outlined above, the ordering provider is required to hold the member harmless. The ordering provider may be responsible for any and all costs to the member and shall reimburse the member for such costs or be subject to claims offset by AmeriHealth for such costs.

If you have any questions, please contact your Provider Partnership Associate or Network Coordinator.