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Provider and Facility Reference Manual

Section 4 - Administrative and Out-of-Plan Referrals

Administrative Referrals


The Medical Director, the Director of Utilization Management or a nurse reviewer may issue an administrative referral for continuity of care or as medically necessary under the following conditions:

  • A new member requires specialty care, but the PCPs office cannot accommodate a new member visit immediately.
  • A new member changes PCPs and current referrals are terminated, but continued specialty care is required.
  • Continuation of active care occurs under the following circumstances:
    • If the provider's participation terminates, the member may continue to receive care for up to 90 days. The 90 day transitional period begins on the date the provider's contractual obligation with the health plan to provider services terminates.
    • If the member is in the second or third trimester of pregnancy, she may continue receiving care from a terminated provider through delivery and the postpartum period.
    • New enrollees in the second or third trimester of pregnancy may continue to see out-of-network providers for delivery and postpartum care.
    • New enrollees who are disabled, or have degenerative and/or life-threatening conditions or diseases, may continue to see out-of-network providers for up to 60 days from the date of enrollment.

Specialty Care Coordinators

Certain medical conditions require a specialist or specialty-care center to provide and/or coordinate the member's primary and specialty care. In these cases a specialty care coordinator (SCC) may be designated. The Medical Director must approve the designation of SCC.

The SCC does not require a referral from the primary care physician (PCP) and may authorize referrals, procedures and other medical services to the same extent the primary care provider would be able.

Such referral shall be made pursuant to a treatment plan developed by a specialty care center and approved by the HMO, in consultation with the primary care provider, if any, or specialist. Among other things, the treatment plan may set time limits on the SCC's authority or may establish the scope of services that may be provided or authorized by the SCC.

To be eligible for care by a Specialty Care Center, the member must be afflicted with the following, which will require specialized medical care over a prolonged period of time:

  • A life threatening condition or disease, or;
  • A degenerative and disabling condition or disease.

Diagnoses that may be classified as degenerative and disabling conditions may include but are not limited to:

  • Cancer
  • Cerebral Palsy
  • Conditions necessitating an organ transplant
  • Cystic fibrosis
  • Hemophilia
  • HIV/AIDS
  • Multiple Sclerosis
  • Sickle Cell Anemia

A Specialist Care Coordinator may be requested by:

  • the member (upon enrollment)
  • the member's current PCP
  • the member's specialist

A Specialist Care Coordinator who is not a participating provider will only be approved if the Medical Director determines that we do not have a provider in the network with the appropriate training and expertise to provide the care necessary, and that a Specialist Care Coordinator is required and appropriate.

Members receiving care by a Medical Director-approved Specialty Care Center that is a non-participating provider, cannot be required to pay any more out-of-pocket expense than they would have when treated by a participating provider.

Summary of Specialty Care Coordination Process

  1. Request for Specialist Care Coordinator.
  2. Utilization Management (UM) reviews patient history and discusses request with patient, PCP, specialist, and Medical Director.
  3. Decision is rendered with one of the following options:
    1. Maintain PCP, but allow one year referral to specialist
    2. Request new PCP with appropriate sub-specialty
    3. Request SCC for patient
  4. Letter sent to member, provider and specialist with decision determination.

Specialty Care Centers

A Specialty Care Center is a center accredited or designated by an agency of the state or federal government or by a voluntary national health organization as having special expertise in treating the disease or condition for which it has been accredited or designated. If we determine that our provider network does not have a Specialty Care Center with the appropriate expertise to treat a member's disease or condition, the member's PCP may request a referral to a non-participating provider. To request a referral, the PCP may contact our Utilization Management Department at 1-800-677-3086.

Summary of Specialty Care Coordination Process:

    1. Request for Specialty Care Coordinator.
    2. Utilization Management (UM) reviews patient history and discusses request with patient, PCP, specialty, and Medical Director.
    3. Decision is rendered with one of the following options:
      • Maintain PCP, but allow one year referral to specialist
      • Request new PCP with appropriate sub-specialty
      • Request SCC for patient
    4. Letter sent to member, provider and specialist with decision determination.

If we determine that a member's disease is life-threatening, or degenerative and disabling, and will require specialized medical care over a prolonged period of time, we will authorize an in-network referral to a Specialty Care Center that has the expertise to treat the member's disease or condition.

Out-Of-Plan Referral


Out-of-plan (OOP) referrals for urgent care are made to providers or facilities not participating with Blue Cross Blue Shield when:

  • the member is outside the Blue Cross Blue Shield service area
  • participating providers in the area cannot provide the necessary services

OOP referrals are made by the PCP or specialist and require review by the Utilization Management Department.
If you believe that the service is materially different then what is available in- network we require:

  1. a written statement from the enrollee's attending physician, who must be a board certified or board eligible physician qualified to practice in the specialty area of practice appropriate to treat the enrollee for the health service requested, that the requested out-of-network health service is materially different from the health service the health care plan approved to treat the insured's health care needs; and
  2. two documents from the available medical and scientific evidence that the out-of-network health service is likely to be more clinically beneficial to the enrollee than the alternate recommended in-network health service and for which the adverse risk of the requested health service would likely not be substantially increased over the in-network health service.

If you believe that there is not an appropriate in-network doctor who can provide the service needed, we require a written statement from you explaining:

  1. Why in-network doctors do not have the appropriate training and experience to meet particular needs; and
  2. Why you recommend an out-of-network doctor who has the appropriate training and experience and is able to provide the service.

You must be licensed and board certified or board eligible, and qualified to practice in the specialty area appropriate for the treatment needed.

The member's care should be directed to an in-network provider as soon as his or her condition(s) permits it.

Out-of-Plan referrals cannot be backdated.

Examples of Out-of-Plan Coverage

OOP referrals are not made for patient convenience. The following circumstances must apply:

  1. The covered service is not available from a participating in-network provider
  2. A specialty provider is not available in-plan
  3. Possible access issues

If the services are deemed necessary and are a covered service to a member in-network, the plan will adequately and timely cover these services for as long as the plan is unable to provide the service in-network.

Second opinions will also be arranged for a member should an appropriate professional not be available in-network. This will occur at no more cost to the member than if the service was obtained in-network.

Travel Time and Distance Standards:

  • 30 minutes or 30 miles for PCPs.
  • For all other providers, it is preferred that they satisfy the 30-minute or 30-mile standard (not required).

This does not apply for patient convenience.
The above 30 miles/30 minutes travel time rule does not apply to a specialty M.D.

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. Referrals must be requested within 48 hours of services being rendered.

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. The PCP needs to contact Blue Cross Blue Shield to coordinate the required referral for out-of-area urgent care.