Name of Manual - Blue Cross and Blue Shield of Minnesota

Referrals
Blue Plus
Overview When Blue Plus members are referred by their PCC to other
providers, Blue Plus needs to be notified by the PCC in order for
claims to process correctly. A referral is not a guarantee of
payment, but allows the patient to seek medical care outside
the PCC. A referral does not negate the necessity of a prior
authorization or preadmission notification, if they are required.
Referrals are in addition to both of these procedures for managed
care products.
Once the referral is received from the PCC, Blue Plus will generate
a referral letter depending on the type of referral (see Referral
Letter).
It is the referred provider’s responsibility to communicate medical
assessments and proposed treatment plans to the PCC. To best
coordinate the member’s care, the PCC must have complete
medical information. PCCs may request the information in the
format of their choice.
Referral Policy The referral process occurs when a PCC determines that the
patient’s condition requires care outside his or her PCC. A referral
is initiated by the PCC and is limited to a specific duration and
number of visits, as determined by the PCC. There are some
situations where a referral is not required (see Referrals Not
Required). A prior authorization may be necessary. See the
section on Prior Authorization, Section 6-16. Policies for
Government Programs may have different requirements. See
Chapter 3 in the Blue Plus Provider Manual.
The goal of the referral process is to ensure continuity of care
through coordination with the PCC. When care needs are identified
which cannot be appropriately provided by the PCC, care is
referred.
The objectives of referrals are:
• To promote coordination of care and communication between
patients, PCCs and specialty providers.
• To promote appropriate use of referral care, thereby reducing
under-utilization or over-utilization of services.
• To promote seamless, quality of care delivery by facilitating
the use of a select, coordinated network of primary care and
specialty providers.
Blue Cross Blue Shield of Minnesota Provider Policy and Procedure Manual (12/27/10) 6-11