What is referral in Medical billing - out of plan referral

Referral.  

When the referring provider, in writing, transfers complete responsibility of treatment for a specific and/or suspected problem, the receiving provider may not code a consult.  Referrals are “evaluate and treat.”  Outpatient referrals are coded using E&M codes for office visits as the new provider assumes full control of the patient.  Inpatient referrals require the patent be transferred to the new service, at which time the new service begins coding codes from the appropriate Inpatient Hospital Services codes (unless there is a decision for surgery in which case the new attending surgeon would code 99499). 

A written order from your primary care provider for you to see a specialist or get certain health care services. In many health maintenance organizations (HMOs), you need to get a referral before you can get health care services from anyone except your primary care provider. If you don’t get a referral first, the plan may not pay for the services.


    Example:

Consult:  Family practitioner asked the opinion of a pulmonologist regarding treatment options for a patient newly diagnosed with left-lower-lobe pneumonia and cough.

Referral:  Family practitioner requests that a pulmonologist take over the treatment of a patient newly diagnosed with left-lower-lobe pneumonia.  The chart notes indicate that the family physician will continue to manage the patient’s leukemia (initial reason for admission).

Out-of-Plan Referral Guidelines

Out-of-Plan (OOP) referrals should only be requested for BlueCross BlueShield patients when:

• The patient is outside their service area
• Participating providers in the area cannot provide the necessary services

Services must be requested by the patient’s PCP or participating specialty provider.

A request form for OOP coverage can be found on our website.

The following information is required:

Office notes, consultation reports, diagnostic studies, and in-plan provider documentation that supports the need for the patient to be seen by an OOP provider

• OOP provider name (requesting provider, assistant surgeon, co-surgeon)
• OOP provider address
• OOP provider specialty
• Planned services CPT® codes, if applicable
• OOP provider assistant/co-surgeon information (link to email to the new  process change)


Definitions:

Non-participating provider: A provider (e.g., facility, vendor, physician, or other clinician) who does not participate with any BlueCross/BlueShield plans; claims submitted by a non-participating provider (NPP) will process to the patient’s out-of-network (OON) benefit unless an out-of-plan (OOP) referral is on file.

Out-of-Network Provider (OONP): A provider (e.g., facility, vendor, physician, or other clinician) who does not participate with the patient’s Home Plan but does participate with the BlueCross/BlueShield plan in the provider’s local area. Claims submitted by an OON provider will process to the patient’s OON benefit unless an OOP referral is on file.

Out-of-Network Benefits: Coinsurance, copay, and/or deductible that the patient is financially responsible for when receiving services from a NPP or OON provider. Typically, when a patient uses their OON benefit, they encounter higher out-of-pocket costs.


Primary Care Provider

A physician, including an M.D. (Medical Doctor) or D.O. (Doctor of Osteopathic Medicine), nurse practitioner, clinical nurse specialist, or physician assistant, as allowed under state law and the terms of the plan, who provides, coordinates, or helps you access a range of health care services.


Provider

An individual or facility that provides health care services. Some examples of a provider include a doctor, nurse, chiropractor, physician assistant, hospital, surgical center, skilled nursing facility, and rehabilitation center. The plan may require the provider to be licensed, certified, or accredited as required by state law.

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