Referrals and Prior Authorizations
If you enroll in HealthSelectSM of Texas, you will need to designate a primary care physician (PCP) who is in the HealthSelect network to receive the highest level of benefits. Your PCP is responsible for directing your care, as well as making any necessary referrals to specialists in the HealthSelect network.
Referrals and prior authorizations issued by UnitedHealthcare before September 1, 2017, will be transferred to BCBSTX. If the provider is still in the HealthSelect network, referrals and prior authorizations will be honored through the original expiration date. For specialists who will no longer be in the network, referrals and prior authorizations will be honored for 90 days.
After September 1, 2017, all new referrals and prior authorizations will need to be issued by BCBSTX.
A referral is a written order from your PCP for you to see a specialist or get certain medical services. For most services, you need to get a referral before you can get medical care from anyone except your PCP. If you don’t get a referral before you receive services, you will get non-network benefits. In most cases, a referral is good for 12 months.
Referrals are required so that your PCP coordinates any specialist care you might need. This can reduce unnecessary visits to specialists for care that your PCP can provide, which helps keep plan costs low.
You do not need a referral for:
- Routine and diagnostic eye exams
- OB/GYN visits, mental health counseling
- Chiropractic visits
- Occupational therapy and physical therapy
- Virtual visits, urgent care centers and convenience care clinics
Prior authorization is required for certain covered health services. In general, your network PCP and other network providers are responsible for obtaining prior authorization before they provide these services to you. There are some covered health services, however, for which you are responsible for obtaining prior authorization. Prior authorization is required even if you have a referral from your PCP to seek care from another network physician.
Personal Health Assistants can help you if you have questions about your HealthSelect benefits, including what services require referrals and prior authorizations. PHAs can also work with your doctor’s office to help coordinate referrals and prior authorizations for you so that you can focus on getting the care you need.
Personal Health Assistants are available by phone Monday-Friday from 7 am-7 pm CT, and on Saturday from 7 am-3 pm CT. Call a Personal Health Assistant toll-free at 800-252-8039.
Prefer to chat online? Personal Health Assistants are available online Monday-Friday from 8 am-5 pm CT.
Beginning September 1, you will be able to view the status of referrals and prior authorizations by logging in to the HealthSelect secure member website.
Continuing and transitioning care
If you are currently receiving treatment from a doctor who will not be in the BCBSTX HealthSelect network after September 1, 2017, you may be able to continue treatment with that doctor temporarily. This is called transition of care. To continue with your care, certain eligibility guidelines need to be met. A transition of care form is available for you to submit to BCBSTX by mail or fax.
To determine whether you qualify for transition of care, it may be necessary for BCBSTX to request medical information from your current physician(s).
If you are approved for transition of care, in-network benefits may be available for up to 90 days after September 1, 2017. After that, your benefits will be determined by BCBSTX.
Medical conditions that may be eligible for transition of care benefits include:
- Pregnancy in the second and third trimester
- Long-term treatment of cancer, heart disease or transplants
- Terminal illness if life expectancy is less than six months