Maryland Point of Service Changes
Responding to requests from customers and providers, CareFirst BlueCross BlueShield (CareFirst) is making it easier for many members to see specialists without having to first obtain a referral from their Primary Care Physician (PCP). As of June 1, 2001 a number of administrative referral requirements were eliminated under the Maryland Point of Service (MPOS) plan. MPOS members will automatically receive in-network benefits for certain services rendered by CareFirst Preferred Provider Network (PPN) physicians, without requiring the PCP to submit a referral form to CareFirst. Some services, like medical supplies, will be paid in-network even when provided by an out-of-network provider.
Although written referrals are not required to receive an in-network benefit, members should still discuss their health care needs with their primary care physician prior to going to a specialist. The PCP's guidance remains an important factor in making decisions about specialty care treatment options. A written referral to direct patient care to a PPN provider continues to be highly recommended.
This move to simplify the referral process will make the administration of these specialty services easier, faster and less expensive for members, providers and CareFirst. Patients should confirm their specialty provider's status by checking with the CareFirst Referral Unit or by asking the provider directly. The Referral Unit can be reached toll free at: 800-235-5160. Direct access to specialty services is not extended outside the service area under BlueCard provisions.
Removing referral requirements affords several benefits to members, brokers and CareFirst because:
- CareFirst has not increased premium costs to members.
- Administrative complexity and related internal costs are
reduced.
- Risk for abuse, overuse or misuse of these services by
members is minimal.
- Actuarial impact is cost-neutral.
Redundant care management by Out Patient Authorization Program (OPAP therapies), Coordinated Home Care (CHC), and other pre-certification programs is elminated.
Services Not Requiring Written Referrals from PCP
| DME (requires DME certification) |
Care Nurses |
MRI, CAT Scan, Holter |
Accidental/Medical |
| Monitor |
Emergency |
| Medical Supplies |
Ambulance |
| Orthopedic Braces |
Hospice |
Occupational Therapy* |
Lab |
Speech Therapy* |
Mammography |
| Physical Therapy* |
Major Organ Transplant |
| Chemotherapy* |
X-rays/Machine Tests |
| Radiation Therapy* |
Artificial Insemination |
| Renal Dialysis* |
GYN (office) |
| Ophthalmology* |
Maternity |
| Oral Surgery* |
In-vitro Fertilization |
| Coordinated Home Health |
Care and Home Health |
All other services require a written referral from a PCP.
*Must be rendered by CareFirst PPN provider
