Reminder: Providers should refer PPO members to other TRUST providers

If it is necessary to refer out-of-network, physician assistants can now make these referrals for PPO members when the appropriate documentation is provided.

According to Blue Cross Blue Shield of Michigan’s referral policy, TRUST providers should refer PPO members to other TRUST providers whenever possible. Because the TRUST network encompasses a large scope of participating providers, referrals to out-of-network providers should occur only in rare cases.

Also, keep in mind:

• Out-of-network referrals are acceptable only when covered services are medically necessary and are not reasonably available within the TRUST network.

• If medically necessary services are not available within the TRUST network, you may advise PPO members that out-of-network deductible and copayments will not apply. However, some member contracts may have in-network deductible and copayments that would still apply.

• PPO members must pay additional out-of-pocket costs when receiving out-of-network services without a referral by a TRUST provider.

Referrals by physician assistants

Now that physician assistants can refer TRUST members to out-of-network providers, the PAs must always include the following:

• TRUST supervising provider’s license number
• Ten-digit National Provider Identifier number that appears on the TRUST Preferred Provider Organization (PPO) Program Referral Form (form number WP 9147) and the CMS-1500 claim form.

If you refer a PPO member to an out-of-network provider, you must complete these steps:

• Advise the PPO member that he or she could be liable for extra cost if the referral is to a health care provider who does not participate in the TRUST network.

• All TRUST providers, including those at facilities and laboratories, must complete the TRUST Preferred Provider Organization (PPO) Program Referral Form prior to a PPO member being referred for services to a non-PPO practitioner, facility, ancillary provider or laboratory. Referrals are only valid up to 60 days after the date of referral and covered services must be performed within one year of the referral date.

• The signature of the TRUST PPO provider or physician assistant, the out-of-network provider and the member must be on the referral form in order for the referral to be valid.

• If submitting paper claims:

• A signed copy of the referral form must be attached to the claim.

• On the CMS-1500 claim form, record the referring provider’s National Provider Identifier number in field 17B of the CMS-1500 claim form. Or, if billing electronically, enter the NPI number in the appropriate field.

• On the UB-04 claim form hospital services, record the referring provider’s NPI number on. Or, if billing electronically, enter the NPI number in the appropriate field.

Retrospective referrals by TRUST providers will not be approved without documentation from the patient’s medical record that indicates the referral was initiated prior to the PPO member receiving services from the out-of-network provider.

Note: The referral process does not apply to Federal Employee Program members. Health providers should ask members to call the FEP Customer Service number at 1-800-482-3600 for information about out-of-network exceptions.

Referrals for out-of-network services are not allowed for the following: Flexible Blue^SM, Simply Blue^SM, Community Blue^SM Group Benefits Certificate SG, all Healthy Blue Achieve products and all products with heath savings accounts. Out-of-network services will be paid as out-of-network.