This is a reminder that commercial HMO and POS and Medicare Advantage HMO
(HMO/POS) members are required to have a referral for specialty care, including
for non-emergency and hospital care. The referral must be issued by the
member?s primary care physician (PCP) through the NaviNet
® web
portal. If an HMO/POS claim is received for specialty services and a referral
is not on file, the claim will be denied for ?no referral.?
Referrals are valid for 90 days and do not guarantee active eligibility on the
date of service. PCPs should be as specific as possible when issuing a
referral. Members who are not eligible on the date of service will be
responsible for payment. All visits must occur within the 90-day period
following the date the referral is issued. Non-emergency services (other than
Direct Access services, which include OB/GYN, infertility, and maternal fetal
medicine) that have not been referred by the PCP will not be covered.
HMO members must be referred to participating providers only. If a
participating provider cannot provide care, and a referral to a
nonparticipating provider is contemplated, such a referral by a PCP would
require IBC?s preapproval.
Please also note the following:
For HMO/POS members. All radiology, outpatient laboratory, and short-term
physical and occupational therapy referrals must be to the PCP?s capitated
site. Note: Providers in Berks, Lancaster, Lehigh, and Northampton counties in
Pennsylvania are not required to choose capitated radiology or short-term
rehabilitation sites.
For Direct POS members. No referrals are required for Direct POS members to see
participating specialists. However, referrals are required for routine
radiology (except mammograms), spinal manipulation, and physical/occupational
therapy services. To receive the highest level of benefits, members should be
referred to the PCP?s capitated site for capitated services (i.e., routine
radiology, physical/occupational therapy, and laboratory).
For additional information regarding referral requirements, please review the
Administrative Procedures section of the Provider Manual for Participating
Professional Providers, which is available on IBC NaviNet Plan Central in the
Current Publications section.
NaviNet® is a registered trademark of
NaviNet, Inc., an independent company.