Medical billing - Blue Medicare HMO referral process

Effective January 1, 2011, Health Options, Inc. (HOI) is instituting a change in the member referral process for all Medicare Advantage (BlueMedicare® HMO and BlueMedicare® Group HMO) members.

 PCP refers a member to a participating specialist. Participating specialist refers a member to another participating specialist.·Notification of a member referral is required when: 

Note: Authorizations are required for all referrals to nonparticipating physicians and providers.

Exempt Covered Services

The following covered services are exempt from the referral requirement: Emergency services Certain specialists including chiropractors, dermatologists and podiatrists Flu shots Laboratory services at a participating Quest laboratory within the member’s service area with a valid prescription Mammograms

The physician or authorized participating specialist is responsible for obtaining any required referral and prior authorization approvals for all services including facility, outpatient, ancillary and professional services. The physician or provider must also verify that the authorization is appropriate, approved and complete before rendering services.

Authorization can be obtained by calling the Utilization Management line at (800) 955-5692. When requesting a prior authorization, please have the following information and supporting medical documentation available: Member name Member number Member date of birth Diagnosis by ICD-9-CM Place of service Dates of services Name of physician, health care professional or facility to perform services Services and procedures requested Other information required by Medicare guidelines