Important Information Regarding Personal Choice/AHC Referrals

When a Referral IS Needed

A Primary Care Physician is required to make a referral in the following cases:

• A Primary Care Physician is required to make a referral in the following cases:
• Sending a Primary Care patient to any other doctor for treatment including diagnostic testing by a cardiologist.
• If the “referred to” specialist needs to send the patient to another physician.
• Treatment/surgery by an OB/GYN when the visit exceeds the maximum number (usually two) of self-referrals allowed by a member’s specific group benefit plan. Pregnancy requires a separate referral.
• Emergency treatment – The patient must notify the physician within 48 hours.

When a Referral is NOT Needed

Referral notification is not required in these situations:

• Treatment rendered by a Primary Care Physician.
• Services by laboratories, pathologists, radiologists and anesthesiologists when ordered by the PCP or specialist for whom there is a referral. EXCEPTION! A referral is required to an anesthesiologist for an epidural when used in pain management.
• Additional physicians treating or consulting during an in-network admission.
• Physical therapy ordered by the PCP or a specialist for whom there is an
  effective referral.
• Ambulance services: EXCEPTION! Uniroyal contracts require a referral.

Referrals to specialists require notification within 72 hours.