Referrals and Prior Authorizations
If you are enrolled in HealthSelectSM of Texas (In-Area), you are required to choose a primary care physician (PCP) to coordinate your health care.
Your PCP is responsible for managing referrals to see specialists. If your visit requires a referral, your PCP must submit the referral request to Blue Cross and Blue Shield of Texas before your appointment.
You can select or change your PCP or review your referral information by logging in to your Blue Access for MembersSM (BAMSM) account or by calling a Personal Health Assistant toll-free at (800) 252-8039.
Referrals are required under the HealthSelect of Texas (In-Area) plan.
A referral is a written order from your PCP for you to see a specialist. 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 out-of-network benefits. In most cases, a referral is good for 12 months.
You do not need a referral for:
- Eye exams (both routine and diagnostic)
- OB/GYN visits
- Mental health counseling
- Chiropractic visits
- Occupational therapy and physical therapy
- Virtual visits, urgent care centers and convenience care clinics
Prior authorization requirements apply to all of the HealthSelect plans, except HealthSelectSM Secondary.
BCBSTX must approve certain covered health services before you receive them. This is called a prior authorization. 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.
You can see the status of your referrals and prior authorizations by logging in to your BAM account.
Continuing and transitioning care
If you are currently receiving ongoing treatment from a doctor who will no longer be in the 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. Fill out and submit a transition of care form . You can submit the form by mail or fax to BCBSTX.
To find out if you qualify for transition of care, BCBSTX may need to request medical information from your current doctor(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