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Provider and Facility Reference Manual

Section 3 - Referral Management

 

  • Effective January 1, 2003, referrals were no longer required for Blue Cross Blue Shield HMO members. This means that primary care physicians can refer Blue Cross Blue Shield members directly to an in-network specialist without contacting the health plan for approval.
  • Effective January 1, 2009 referrals were no longer required for Senior Blue HMO members. This means that primary care physicians can refer Blue Cross Blue Shield members directly to an in-network specialist without contacting the health plan for approval.
  • Referrals are no longer required for Healthy New York, Essential Plan as well as certain Traditional POS plans effective September 1, 2018.

What is HEALTHeNET (wnyhealthenet.com)

HEALTHeNET is a HIPAA-compliant health information network that offers physicians, providers, and office staff access to a patient's health information using simple and fast, web-based transactions.

The following set of transactions that are available online:

Eligibility Transaction (270/271) By using HEALTHeNET, you can confirm your patients' eligibility, primary care physician, correct copay, and benefits in just seconds.
Claim Status Transaction (276/277) This feature will allow you to check the status of your claims, eliminating the need to contact the Provider Service Department.
Referral/Authorization Inquiry(278) Allows you to check the status of referrals and certain types of authorizations for members, eliminating the need to contact the Provider Service Department.
Referral Request Transaction (278) You can submit a referral request on-line, eliminating the need to contact the Utilization Management Department.
Provider Inquiry and Inquiry Summary Transactions Allows you to submit adjustments, with or without attachments to our Provider Service Department.

We encourage you to sign up today to use this tool by completing the online enrollment form located at wnyhealthenet.com.

Urgent Care

Urgent Care is medically necessary treatment that requires prompt attention and is not an emergency. Members are covered for urgent care when away from home through the Blue Cross Blue Shield national network.

Members will call the PCP for guidance, and if treatment is advised, the member will call 1-800-810-2583 to locate a provider in the Blue Cross Blue Shield national network. The member will make an appointment and present their home plan membership card.

Emergency Care

Blue Cross Blue Shield does not preauthorize emergency services and we do not deny emergency care on a retrospective basis, however, we may identify specific diagnosis to pend for medical review to determine if rationale to seek care in an emergency room setting meets the intent of the New York State Prudent Layperson Law. After review by a physician, Blue Cross Blue Shield will treat identified non-emergency care as an adverse determination and all provisions of Adverse Determination Policy will be applied.

Emergency services, including Comprehensive Psychiatric Emergency Program (CPEP) and Office of Mental Health/ Office of Alcoholism and Substance Abuse Services (OMH/OASAS) Crisis Intervention and OMH/OASAS specific non-urgent ambulatory services are not subject to prior approval.

Definition of Emergency Care

Emergency condition means a medical or behavioral condition, the onset of which is sudden, that manifests itself by symptoms of sufficient severity, including severe pain, that a prudent layperson, possessing an average knowledge of medicine and health, could reasonably expect the absence of immediate medical attention to result in (a) placing the health of the person afflicted with such condition in serious jeopardy, or in the case of a behavioral condition, placing the health of such person or others in serious jeopardy; (b) serious impairment to such person’s bodily functions; (c) serious dysfunction of any bodily organ or part of such person; or (d) serious disfigurement of such person.