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Retroactive Referrals and Non-PMD Referrals

Retroactive Referrals

Retroactive or backdated referrals are defined as any referral being generated greater than 72 hours after its effective date. Retroactive referrals are only allowed as a service to permit the Primary Care Physician (PCP) office an opportunity to correct its errors of omission. Retroactive referrals are not acceptable for the purpose of correcting patient noncompliance or self-referral or to facilitate claim payment at a higher benefit level. Please complete the Preferred Care Network (PCN) Retro-Referral form and submit as instructed on the form. Please note that a referral must be input in addition to completion of the PCN Retro-Referral form.

Non-PMD Referrals

The Preferred Medical Doctor (PMD) Physician Agreement requires that the PCP refer only to other participating providers. However, on rare occasions, a situation may arise in which the services needed are not available in the Blue Cross and Blue Shield of Alabama network. Similarly, in other emergency situations, it may be necessary for the patient to seek services from a non-participating provider. In advance of scheduled services and within 48 hours of emergency services, contact the PCP with the referral request. The request and supporting documentation are subject to review by the Blue Cross Medical Director as referral decision is rendered.

Last Updated March 2010