When do I need a referral?
A referral is a recommendation by a doctor that a Member receive health care services from another specialist or facility. Some Referrals may require Pre Authorization.
Referrals to in-network providers are not required if you are an Individual HMO member or a member with HMO Access Blue New England group plans. Referrals to in-network providers are required for all other HMO group plans. All HMO Members (Individual HMO Members, HMO Access Blue New England group Members and all other HMO group plan Members) must obtain a Primary Care Physician (PCP) referral for any out of network service. Failure to secure a referral when required means that no benefits are available and claims for out of network services will be denied.
Referrals to in-network providers are not required for POS BlueChoice New England HSA or HRA plans. To access the highest level of benefits for out-of-network services, members must obtain a Primary Care Physician (PCP) referral.
PPO Members do not need a referral for in-network or out-of-network services.
Your PCP will work with you to decide if you need to see a specialist. If referrals are required, your PCP will refer you to a network specialist. If your plan allows self-referrals to a specialist, you can search for a network specialist in our online directory.
Variations to the standard referral rules may apply. To verify the specific requirements for your plan, including pre-certification for certain services, check your plan document (your contract, Evidence of Coverage, Summary of Benefits, Certificate of Coverage, or Member Handbook, etc.) for details or call Customer Service at the number on the back of your health plan ID card.
What does "preauthorization" mean?
Preauthorization, sometimes referred to as "pre-certification," is the process used to confirm if a proposed service or procedure is medically necessary. Whenever possible, preauthorization should occur before treatment is received.
The physician who schedules an admission or orders the procedure or service is responsible for obtaining preauthorization. Most In-network providers will know to contact Anthem at the Provider Authorization number on the back of your health plan ID card for benefit coverage information and to obtain preauthorization for the care you may be scheduled to receive.
You may also contact Customer Service at the number on the back of your health plan ID card to determine if a proposed test, equipment, service, or procedure requires preauthorization.
It is important to know if your provider has obtained preauthorization, particularly when visiting an out-of-network provider who may or may not be familiar with Anthem’s policies and requirements.
NOTE: Failure of your physician to secure a preauthorization when required may result in denial of payment of a claim.
What services or procedures require preauthorization?
Many health services require preauthorization. Typically, services requiring preauthorization include:
- Overnight stays at a facility, such as a hospital or rehabilitation facility, or continued stays past the number of days authorized.
- Emergency Admissions. Members must notify their health plan within one business day, if reasonably possible, after being admitted to a hospital.
- Surgical procedures, radiology tests, and occupational, speech and physical therapy visits.
Out-of-network providers may not always know or choose not to comply with Anthem’s specific preauthorization requirements. We recommend that you always confirm with your out-of-network provider(s) that preauthorization (or "pre-certification"), has been obtained.
Please check your plan document (your contract, Evidence of Coverage, Summary of Benefits, Certificate of Coverage, or Member Handbook, etc.) for details about covered benefits, copayments, coinsurance, deductibles and exclusions or call Customer Service for help with your questions.
