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Specialist and Primary Care Network Patients

When treating a patient whose benefit plan requires a referral from the primary care physician (PCP), it is the patient’s responsibility to make sure the proper steps are taken to obtain a referral to the specialist. Specialist services should be authorized in advance by the primary care physician. However, specialists should not refuse care because a referral is not on file. Many contracts offer an out-of-network benefit, allowing members to use their self-referral option.

If a specialist has a referral for his patient and determines that the patient needs the services of yet another specialist, a separate referral for the second specialist is required from the PCP. Specialists cannot issue referrals. When a patient is hospitalized by the PCP or is hospitalized by a specialist who has a current referral from the PCP, any other physician services provided during the hospitalization will be covered as in-network without an additional referral. However, once the patient is discharged, any outpatient follow-up services will require a referral for in-network level of benefits. It is the patient’s responsibility to follow up with his PCP after hospital discharge. If the patient is admitted through the emergency room (even if the PCP sees the patient in the emergency room and admits the patient), a hospital facility referral will always be required.

Referrals can be viewed on our website, www.bcbsal.com. To view the referral online, you must be set up with a ProviderAccess individual user identification (ID) and password. To determine whether a referral is required for your patient, you may verify patient benefits through ProviderAccess or through your practice management vendor.