For the first twelve (12) months following implementation BCBSTX will allow members to see Medicaid enrolled, out-of-network providers, in or out of the service delivery area, for Medicaid covered services. Documentation of referrals is not required. Referral is a process that one provider uses to recommend a member to see another provider or specialist. Prior authorization for non-emergency services is required in order to ensure that the provider is loaded in the system and can submit claims. BCBSTX will allow members to see the out-of-network provider and work with the providers to obtain the prior authorization.
1. Client is seeking services from a new specialist where there is no pre-existing relationship.BCBSTX does not require documentation of referrals to Medicaid specialists. BCBSTX does not require prior authorization for in network specialists. BCBSTX will allow members to see out-of-network or out of service area Medicaid specialists for medically necessary services. When the provider is out-of-network members will work with their Service Coordinator so arrangements can be made to ensure that the providers are loaded in our system and that they can file claims.
2. Client is seeking emergency or urgent services from a new specialist.
BCBSTX does not require referrals or prior authorizations for emergency or urgent care for in or out-of-network Medicaid enrolled providers. Members are encouraged to call their PCP during office hours for urgent care or if they already have a specialist that has treated the child for urgent issues they can contact the specialist directly. The PCP may be able to bring the member in for urgent care, or refer the member for urgent care to another provider if the PCP is not able to treat the member and the family does not have another specialist to see. BCBSTX does not require documentation of referrals to Medicaid specialists. BCBSTX will allow members to see out-of-network Medicaid enrolled specialists for medically necessary services.
3. Client is seeking services from a current specialist with whom they have an existing relationship.
BCBSTX has a network of providers for acute care and long term services and supports(LTSS). We are continuously adding to the network. If you feel no one in the network can give your child the care he/she needs, and or you have an existing relationship with a Medicaid enrolled provider, BCBSTX will allow members to see those providers for medically necessary services for up to 1 year. When the provider is out-of-network members will work with their Service Coordinator so arrangements can be made to pay the out-of-network provider. We will reach out and attempt to get these out-of-network Medicaid enrolled providers in network. For specialist with whom the member has an existing relationship, that is not willing to join our network we will offer single case agreement to allow this member to continue to see their existing specialists.