Name of Manual - Blue Cross and Blue Shield of Minnesota

TO THE REFERRAL SPECIALIST
Blue Plus
You or the primary care clinic must approve any hospitalization, tests or special treatments.
Check with the referring physician to determine the participating hospital the clinic uses. Do not
place yourself or the patient at financial risk by performing services not eligible for coverage
under the patient’s health plan, outside the dates specified or for more than the number of visits
approved on this referral, or by admitting to a facility not authorized by the referring physician.
Special instructions from the referring physician:
Please use the space below to provide a written report of services to the referring physician at:
[address of referring physician]
Blue Cross Blue Shield of Minnesota Provider Policy and Procedure Manual (12/27/10) 6-21