Do I Need a Referral?

Wonder if you need a referral, or approval for service, before seeing a specialist or receiving services? While many CareFirst plans do not require referrals, some do.

If your plan requires a referral to see a specialist, you must obtain the referral from your primary care provider (PCP) first—prior to your specialist visit. You will then take the referral to your specialist appointment and submit it before obtaining services.

Examples of plans that require a referral are the Maryland Point of Service (MPOS) plan and some BlueChoice plans.

  • MPOS—All MPOS members must first choose a PCP. A referral from the PCP is required when visiting a specialist in order to receive in-network benefits. MPOS members can see a specialist without a referral, but may pay more out of pocket.
  • BlueChoice—Most BlueChoice plans do not require a referral to see a specialist. However, if your plan does require a referral, your PCP will provide you with the referral prior to your visit with the specialist.

To determine if your plan requires referrals, or for questions about how your benefit plan works, including the referral and preauthorization process (if applicable to your coverage):

  • Log in to My Account and check your benefit details
  • Refer to the benefit guide you received when you enrolled
  • Call Member Services at the telephone number on the back of your member ID card

In general, a referral to a specialist typically covers up to three visits and is valid for 120 days from the date the referral is written.

For members in all plans, your doctor must request authorization for services such as non-emergency hospitalizations, outpatient hospital services and home health care.

Services from Network and Non-Network Specialists

Referrals for Members in HMO Plans

Members in HMO plans should reference his/her member contract to determine if referrals for specialist services are required. Members may also discuss referral requirements with their Primary Care Provider, who will provide a referral when needed.

Referrals may be for a single visit or multiple visits, also referred to as a standing referral. Standing referrals may be issued if the patient has a specific condition such as:

  • A cancer diagnosis, in order to see a board-certified pain management physician
  • A pregnancy, for maternal care and delivery

Or for a condition that

  • Is life threatening, degenerative, chronic, or a disability
  • Requires specialized medical care

Access to Non-Network Providers

Many of CareFirst’s plans offer out-of-network coverage, typically at a lesser level of benefits. However, there are some situations where a member may not have access to a network provider and may be able to access a non-network provider at a network cost-share for deductible, copayment and coinsurance.

Under HMO and non-HMO plans, a member may request authorization to be treated by a non-network specialist if CareFirst does not have in its network a specialist or non-physician specialist with the professional training and expertise to treat or provide health care services for the condition or disease; or if CareFirst cannot provide reasonable access to a network specialist or non-physician specialist with the professional training and expertise to treat or provide health care services for the condition or disease without unreasonable delay or travel.

When access to non-network providers is authorized for the above situations, the service is treated as if it was provided by a network provider for purposes of calculating the member’s deductible, copayment and coinsurance.

If you are unable to find a network provider with the expertise or without unreasonable delay or travel, contact Member Services at the telephone number on the back of your member ID card to initiate your request.

Timeframes for Decisions

Initial determinations for non-emergency authorizations are made within 2 working days of receipt of request. Urgent authorization decisions are made within 24 hours of receipt of request.

Grievance and Appeal Process

If you have a concern regarding the denial of an authorization, you may call the Member Services telephone number on the back of your member ID card. A representative can assist you initiate the appeal process. If you would like to review the procedure for filing an appeal, visit Carefirst.com/appeals. For a printed copy, call Member Services at the telephone number on the back of your card.