Referrals – General Information

Referring Physicians

Participating physicians should use their professional judgment when referring members to other providers. Such referral decisions should be based on the best interest of the member.

In addition, HMSA members enjoy maximum plan benefits when services are rendered by participating providers. When referring HMSA members for specialty services, please keep in mind that they will generally have lower out-of-pocket costs if they are referred to other HMSA participating providers. Surgeons should consider this factor when arranging for anesthesia or assistant surgeon services.

Specialty Providers Receiving Referrals

Claims submitted for referred services should indicate the “referred from” provider’s name (last name, first name, middle initial) in Block 17 of the CMS 1500 claim form. EMC claims should also include the “referred from” provider’s name.

This information must be submitted with claims for any service ordered by a physician. These services can include laboratory tests, X-rays, consultations, anesthesia services, physical and occupational therapy, speech therapy, and diagnostic tests. Claims for these services may be returned if referral information is not included.

Services Rendered to Referred HMO Commercial Members

Even if you do not participate with a patient’s Commerical HMO, you may receive benefit payments for services rendered to HMO commercial members if an HMO commercial health center physician has referred the member to you or if the services are being rendered to treat an emergent condition. For services rendered outside of an HMO commercial member’s health center, claims may be denied if the name of the referring physician is not indicated in Block 17 of the CMS 1500 claim form.

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