Keep costs down by referring your patients to specialists who are covered by their plan. Timely referrals can also help avoid claims reviews later. Reviews can hold up payments.
Our guidelines for patient referrals allow us to authorize:
- Exact procedure code referrals – These are referrals submitted with code(s) other than 99499. Primary care physicians (PCPs) should use these referrals when a member needs care for a specific health reason. We will only reimburse for the procedure code(s) that matches the code(s) on the referral.
- C&T referrals – These are referrals submitted with CPT code 99499. In most areas, consult and treat (C&T) referrals do not need to include the specialists’ procedures. We will pay specialists for performing associated covered services in an office setting, according to current claims processing guidelines.
Referrals submitted without a procedure code will default to a C&T referral (99499). Authorized procedures are subject to the number of visits on the referral.
We do not accept procedure codes for services that require precertification. We will return such requests and ask you to resubmit the code(s) using the precertification process. In some instances, we will grant a "modified" response where C&T code 99499 replaces the rejected procedure code.
Submit an electronic referral in one of two ways:
Submit patient referrals through our secure provider website
Submit patient referrals through one of our vendors
Learn more about our referral policy in the Office Manual for Health Care Professionals
Understanding electronic referrals (PDF)
*Our referral system recognizes when a specialty capitation arrangement may apply. As appropriate, we will substitute the "referred to" provider with a provider who is aligned to the capitation arrangement of the requesting provider. In these situations, we will issue a "modified" response.