09/05/2024
When Indian Health, Tribal and Urban Indian facilities refer American Indian and Alaska Native members who are on limited cost-sharing plans to a non-I/T/U provider they need to submit the Limited Cost-sharing Referral Form to Blue Cross and Blue Shield of Texas. You can access the form on the Forms page on our website. If you have a previous version of this form, please replace with new version. (The previous fax number for pharmacy referrals was changed to an email address.)
Note The form has one page for medical referrals and second page for pharmacy. Be sure to submit the appropriate form based on type of service.
Background: American Indians and Alaska Natives on limited cost-sharing plans can get treatment from Indian health care providers at Indian Health Service, Tribal and Urban Indian facilities. But if they need services unavailable through I/T/U facilities, they can get care from a different provider without paying anything out of pocket, if they have a referral.
The medical version of the form can be faxed to our Payment Services Claims Processing area at 918-549-7777 or mailed to:
Attn: I/T/U Referral
7777 East 42nd Place
Tulsa Oklahoma 74145
The pharmacy version of the form can be emailed to the Retail Service Coordinators.
Reminder: Pharmacy claims are processed when a member fills the prescription at the pharmacy. Members may have to pay out of pocket for prescriptions filled without an I/T/U referral.