Referrals for BlueChoice HealthPlan Members

Referrals for BlueChoice HealthPlan Members

6/22/18

BlueChoice HealthPlan Health Maintenance Organization (HMO) members must have a referral from their assigned primary care physician before seeking the services of specialists. Once the primary care physician determines a member needs the services of a specialist, the primary care physician is responsible for notifying our Health Care Services department before sending the member to the specialist. 
 
The best way to make referrals to specialists is through our website at www.BlueChoiceSC.com. Referrals made through our website are loaded instantly and immediately assigned an authorization number. Just follow these simple steps: 

  1. Go to www.BlueChoiceSC.com.
  2. Select Providers from the main menu.
  3. Under My Insurance Manager, select Log In.
  4. Enter your Username and Password (or select Create New Profile if this is your first visit to our website).
  5. Select Authorization/Pre-Certification/Referral.

Please be prepared to enter the member’s identification number and date of birth. You will also need to know the specialist’s last name and specialty type. Once the referral is complete, you should print a copy of the referral confirmation and fax it to the specialist’s office.
 
If your office does not have access to the Internet, you can use the Referral Partner Authorization form instead. The member’s assigned primary care physician’s office should complete the form. Once the form is completed, the primary care physician’s office should fax a copy to BlueChoice® and the specialist’s office the same day you make the referral.
 
Referrals made by the primary care physician only include office visits and office-based procedures that do not require prior authorization. Referrals do not include approval for procedures/services that require separate authorization.
 
You cannot use Web referrals or the Referral Partner Authorization form to request authorization for these services: 

  • Referrals to non-contracting specialists
  • Referrals for routine vision care
  • Referrals for mental health and substance abuse services
  • Durable medical equipment and home care services
  • Referrals with diagnosis of obesity, infertility, impotence, or for cosmetic surgery (or any other possible contract exclusion)
  • Inpatient or outpatient facility services
  • Other procedures or services that require prior authorization

If you would like to request any of these services, please contact our Health Care Services department at 800-950-5387 to get prior authorization.
 
Primary care physicians and specialists can request specialist referral extensions on the web. The Authorization/Pre-Certification/Referral screen in My Insurance Manager includes an option through the Request Extension button or by going through the Check Status button. Only approved office visit referrals are available for extension (CPT 99201-99255), and specialists may only extend their own referrals.
 
Other Important Information

  • Referrals are valid for six months. 
  • If it has been longer than six months, the specialist must contact the primary care physician for a new referral.
  • We do not accept requests for referrals retroactively. 
  • Specialists are responsible for making certain they have valid referrals before seeing members.
  • Use the web to ensure BlueChoice has received the referral. 

If you have any questions about this bulletin, please contact Provider Education by using the Provider Education Contact Form or by calling 803-264-4730.