Common use of HOW TO OBTAIN A SPECIALIST REFERRAL Clause in Contracts

HOW TO OBTAIN A SPECIALIST REFERRAL. Members should always consult their Primary Care Physician first when they need Medical Care. If the PCP determines that the Member needs specialized services, the PCP will refer the Member to the appropriate Participating Provider. Some services will also require Preauthorization form Keystone. Referrals are valid only for the provider to whom the Member was originally referred. Members who wish to change the specialist to whom they have been referred should contact their PCP. When the PCP refers the Member for Medically Necessary care, the PCP will issue a referral. The referral notification will indicate the services to be performed by the specialist or facility and any specific time frame for which the referral is valid. The specialist or facility must contact the PCP before providing additional services not originally referred. It is important to note that all laboratory services must be obtained using the PCP’s laboratory arrangement listed on the Member’s ID card. Certain services require Preauthorization by Keystone. Members should consult the enclosed listing for services that require Preauthorization. To avoid delays in claims payment, Members should consult with their Provider prior to having services rendered to ensure that the proper Preauthorization has been obtained from Keystone for the listed services. Members must be enrolled at the time they receive services from a Referred Specialist or Non- Participating Provider in order for services to be covered. See the Preauthorization for Non-Participating Providers section of this Subscriber Agreement for information regarding services provided by Non-Participating Providers. Services by Non-Participating Providers require Preauthorization by the HMO in addition to the electronic Referral from your Primary Care Physician.

HOW TO OBTAIN A SPECIALIST REFERRAL. Members should always consult their Primary Care Physician first when they need Medical Care. If the PCP determines that the Member needs specialized services, the PCP will refer the Member to the appropriate Participating Provider. Some services will also require Preauthorization form from Keystone. Referrals are valid only for the provider Provider to whom the Member was originally referred. Members who wish to change the specialist to whom they have been referred should contact their PCP. When the PCP refers the Member for Medically Necessary care, the PCP will issue a referralReferral. The referral Referral notification will indicate the services to be performed by the specialist or facility and any specific time frame for which the referral is valid. The specialist or facility must contact the PCP before providing additional services not originally referred. It is important to note that all laboratory services must be obtained using the PCP’s laboratory arrangement listed on the Member’s ID card. Certain services require Preauthorization by Keystone. Members should consult the enclosed listing for services that require Preauthorization. To avoid delays in claims payment, Members should consult with their Provider prior to having services rendered to ensure that the proper Preauthorization has been obtained from Keystone for the listed services. services.‌ Members must be enrolled at the time they receive services from a Referred Specialist or Non- Participating Nonparticipating Provider in order for services to be covered. See the Preauthorization for Non-Participating Nonparticipating Providers section of this Subscriber Agreement for information regarding services provided by Non-Participating Nonparticipating Providers. Services by Non-Participating Nonparticipating Providers require Preauthorization by the HMO in addition to the electronic Referral from your Primary Care Physician.