Referrals and Prior Authorizations
If you are enrolled in HealthSelectSM of Texas, you are required to choose a primary care provider (PCP) to receive the highest level of benefits and keep your health care costs down. Your PCP serves as your first point of contact when you need non-emergency medical care.
Your PCP is responsible for coordinating your care, making referrals to see specialists and writing orders for lab and imaging services. To receive in-network benefits, your PCP will need to submit a referral to Blue Cross and Blue Shield of Texas (BCBSTX) before your visit. If you do not have a referral on file before you see a specialist, you will pay more, because your visit will be considered out-of-network. Your specialist or lab services facility also must be in-network for you to receive in-network benefits. You can verify network status by calling a BCBSTX Personal Health Assistant toll-free at (800) 252-8039.
Select your PCP before getting care
You have 60 days from the effective date of your coverage to select a PCP. Once you make your PCP selection, all services must be coordinated through your PCP in order to receive in-network benefits. After 60 days, if you still have not selected a PCP, out-of-network benefits will apply for any services you receive.
You can select or change your PCP by calling a BCBSTX Personal Health Assistant toll-free at (800) 252-8039 or by logging in to Blue Access for MembersSM:
- If you already have a Blue Access for Members account, log in using your username and password. Otherwise, register for Blue Access for Members following the instructions on the screen.
- Once you’re logged in, go to the “Doctors and Hospitals” tab.
- Click “Select Primary Care Physician.”
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:
- Covered vision care, including 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 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 Blue Access for MembersSM account.
Continuing and transitioning care
If you are currently receiving ongoing treatment from a doctor who is leaving the HealthSelect network, 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 your doctors leave the network.
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