BCBSAZ-approved Referrals for in-network specialist office visits (includes telemedicine)
About specialist referrals
To help support in-network, coordinated care, designated PCPs must submit referral requests to BCBSAZ for office visits to most in-network specialists. The following provider types do not need a referral as long as the provider is participating in the network associated with the member's benefit plan:
- OFFICE-BASED SERVICES
- OB-GYN professionals
- Behavioral/Mental Health professionals
- OP Therapy – PT/OT/ST (precert is required after meeting the allowed limit of 60 visits combined for Habilitative and Rehabilitative visits)
- Dental and vision services for eligible members (age 18 or younger, until the end of the policy year in which the member turns age 19)
- NON OFFICE-BASED SERVICES
- Urgent Care Centers
- Retail Health Clinics (please note: CVS MinuteClinics are not in-network for Neighborhood HMO benefit plans)
- Facilities (hospitals, radiology centers, labs, PT/OT/ST, SNFs, mental health facilities, etc.)
For all other specialist office visits, members will have no coverage (claim will be denied) and have to pay for office visits if they do not have a BCBSAZ-approved referral from their designated PCP (or a qualified PCP – see information above on Covering PCPs) on file with BCBSAZ. Members may view the status of a referral on the BCBSAZ secure member portal at azblue.com/member.
Referrals to providers who do not participate in the network associated with the member's benefit plan must be pre-certified. Failing to obtain precertification for out-of-network services will result in a claim denial, except for emergency services.
About the BCBSAZ process for referral approvals
The BCBSAZ referral approval process helps support coordinated, in-network care with three simple and proactive steps:
- The designated PCP (or covering PCP) submits a referral request to BCBSAZ.
- BCBSAZ validates that:
a) The referral request was submitted by the designated PCP (or qualified covering PCP) in advance of the service.
b) The referral is to an in-network specialist.
- If both of the above conditions are validated, BCBSAZ approves the request.
How long does a referral last?
For services that don’t require precertification, a BCBSAZ-approved specialist referral covers all office services rendered by that specialist (or another provider in the same tax ID and specialty, for the same type of specialty services) for up to one year.
For services that require precertification, the referral is specific to that particular service and the precert will not be approved unless the BCBSAZ-approved referral is in place. The timeline of the referral will correspond with the timeframe of the precertification.
Who is included for a specialist referral?
When a member is referred to a specialist, providers in the same tax ID and specialty are included for the referral,
including other MDs, DOs, NPs, and PAs if they are contracted with BCBSAZ.
How to request or view a referral for a member with a PCP Coordinated Care HMO Plan
- Online Tool for Referrals/Precert – available 24/7 on the secure provider portal, this tool works only for members with PCP Coordinated
Care HMO Plans. You cannot use it for members with any other type of benefit plan. When using the online tool for referral requests, the approval process is automated with results displayed on the status page almost immediately.
Sample of Online Tool "Status" page:
- Finding and using the online tool for referrals/precert – two locations!
Fax form – for referral requests. Download the Fax Form – also available in the secure provider portal.
- In the secure provider portal: “Practice Management” > “PCP Coordinated Care HMO,” > “Submit/View Referrals and Precertification."
- On the member's “Eligibility and Benefits Detailed Results” page, click on “Submit/View Referrals and Precertification."
(Approval status is faxed back by the next business day.)
Phone – for referral requests or status, call:
PCP Coordinated Care HMO Provider Service: 1 (844) 807-5106. (Approval status is available by the next business day if it can’t be issued during the call.)