Resources

When a Referral IS Needed

A primary care physician (PCP) is required to make a referral in the following cases:

• Sending a Personal Choice Network (PCN) member to a specialist for treatment, including diagnostic testing by a cardiologist  
• If the referred-to specialist needs to send the patient to another specialist  
• Hospital emergency room (ER) visit or admission; the patient must notify the PCP within 48 hours of the emergency. This is the only time a referral is required for a hospital.

When a Referral is NOT Needed

Referral notification is not required in these situations:

• Treatment rendered by a PCP or provider covering for the PCP  
• Services by laboratories, pathologists, radiologists and anesthesiologists when ordered by the PCP or specialist for whom there is a referral  
• Additional physicians treating or consulting during an in-network admission  
• Physical, occupational and speech therapy ordered by the PCP or a specialist for whom there is an active referral  
• Ambulance services

Referrals for members with the Personal Choice Network plan must be submitted online via ProviderAccess. Do not fax original referral forms to Blue Cross for submission of the referral. Referrals to specialists require a 72-hour pre-notification. If a referral is denied, a retroactive referral form must be faxed to Blue Cross referencing why the referral was denied. Referrals may only be approved if the denial is a result of a PCP error.

To view a list of members who have designated you as their PCN physician, log in to ProviderAccess, hover over Patient & Claim, and then select "PCN Activity Report." Covering physicians may be added and deleted for the PCP as well under "Covering Physicians."