Important Notice to Primary Care Providers and In-Network Specialist Providers

Date: 11/01/20

IMPORTANT NOTICE TO PRIMARY CARE PROVIDERS AND IN-NETWORK SPECIALIST PROVIDERS ABOUT REFERRALS TO IN-NETWORK SPECIALIST PROVIDERS

Expectations of Primary Care Providers:

• When medically necessary care is needed beyond the scope of what a Primary Care Provider (PCP) provides, PCPs should initiate and coordinate the care members receive from In-Network Specialist Providers.
• PCPs are REQUIRED to do referrals for members to seek care from In-Network Specialist Providers.
• PCPs ARE NOT REQUIRED to do referrals to In-Network Specialist Providers for Mental or Behavioral Health services. 
• PCPs ARE NOT REQUIRED to do referrals to In-Network Specialist Providers for Obstetrical or Gynecological Treatment and members may seek care directly from an In-Network Obstetrician and Gynecologist.
• If a member has a condition that requires ongoing care from an In-Network Specialist Provider, the member may request a standing referral from their PCP.
• Consistent with 45 CFR 156 and Ill. Admin Code 2051.290(b), all PCPs must keep accurate and complete patient medical records for Ambetter of Illinois members. 
  • To be considered a complete and comprehensive medical record, PCPs must include referrals to specialists in the member’s medical record.

Expectations of In-Network Specialist Providers:

• For all claims with service date of January 1, 2021 forward, In-Network Specialist Providers must include the referring PCP on their rendering service claim to avoid potential delay in processing.