Referral Requirements

Utilization Management is available to assist providers in identifying a network specialist and/or arranging for specialist care. Here are some other items to keep in mind when referring members:

• Authorization from Utilization Management is not required if referring a member to an in-network specialist for consultation or a nonsurgical course of treatment.
• Authorization from Utilization Management is required when referring to an out-of-network specialist.

All providers are responsible for documenting referrals in the member’s chart and requesting that the specialist provide updates as to the diagnosis and treatment plan.

BCBSTX recognizes that there may be instances when an out-of-network referral is justified. Service Coordination and/or Case Management will work with the medical director and the primary care provider to find appropriate out-of-network providers when medical necessity for services has been determined. Out-of-network referrals will be authorized on a limited basis. Case Management may be contacted at 1-877-688-1811 for questions regarding referrals to out-of-network providers.

Blue Cross and Blue Shield of Texas (BCBSTX) wants members enrolled in Medicaid Managed Care to receive the best possible care. For this to occur, we believe it is important for our members’ Primary Care Provider (PCP) to oversee all medical care, even when members are referred to another provider for services. However, we also realize there are cases where other providers will make referrals for our members. This referral requirement, outlined below, is also requested by the Texas Health and Human Services Commission (HHSC) and helps us to achieve this goal. This process also ensures that your referral-related claims are processed quickly and efficiently.

Currently, specialists and other providers must obtain a referral from a BCBSTX member’s PCP or referring provider prior to treating that member. The PCPs and referring providers should provide their National Provider Identifier (NPI) to specialists when referring Medicaid Managed Care members and must maintain a record of that referral in members’ medical records. Effective September 1, 2013, BCBSTX began denying claims from physicians who have not included the referring provider’s NPI on the claim.

To indicate a referral has been obtained, the referring provider’s name must be entered in Box 17 and the NPI must be entered in Box 17b of the Centers for Medicare and Medicaid Services (CMS) CMS-1500 claim form or in Loop 2310A for electronic data interchange (EDI) claims when submitting claims to BCBSTX. If the referring provider is affiliated with a Federally Qualified Health Clinic (FQHC) or Rural Health Clinic (RHC), the provider may submit the Type I/Individual NPI or the Type II/Group NPI.

Providers can obtain the NPI from the referring provider’s office or from the NPI Registry website .

Please note: This billing requirement is only for referrals and does not change the current Prior Authorization requirement and guidelines. Refer to the Provider Operations Manual for details about Prior Authorization.

The following Primary Care Physician types do not require a referring NPI:

• Family Practitioner
• General Practitioner
• General Pediatrics
• Internal Medicine
• Nurse Practitioner
• OB/GYN
• Physicians Assistant

The referring NPI is not required when billing for the following services:

• Services from OB/GYNs
• Services from Indian Health Providers
• Urgent Care Center Services
• Health Department Services
• Anesthesia Services
• Ambulance Services
• Chiropractor
• Early Childhood Intervention (ECI)
• Emergency Services
• Family Planning
• Health Education
• Inpatient Services
• Immunizations/administrations
• STD/HIV Services – Testing and Treatment

• The member has not been assigned a PCP
• Newborn visits for the first 30 days of life
• Sports physicals

To help our providers with the process, BCBSTX has provided an optional Record of Referral to Specialty Care form. The form has been updated to include a field for the referring providers’ NPI.

The referring providers can fax the form to the specialist to ensure that the specialist has his or her NPI. If the referring provider’s NPI number is not provided, the specialist is responsible for contacting the referring provider’s office to obtain the NPI number.

Note: A Record of Referral is valid for as long as the member is under the care of the specialist or other provider. If the optional form is not used, it is important to maintain a record of the referral in the patient’s medical records.

BCBSTX’s Member Outreach Team will continue to work to reinforce with members that they are responsible for seeing their assigned PCP. Should members tell us that they would like to change their PCP, we will also remind them what steps to take in order to do so.