Referral Guidelines

Our Referral Department can be reached at 206-326-2453, option 1

For complete details, please refer to your Member Handbook.

USFHP pays for covered medical services when they are provided by your primary care provider (PCP). For other services, your PCP may refer you to another provider. These services might include specialists, hospitals, and rehab facilities. The Plan pays for other covered services when they are authorized in advance by US Family Health Plan.

The only services for which you do not need a referral in advance are:

  • Behavioral health (first eight visits with a USFHP network provider)
  • Emergency care
  • Annual eye exam**
  • Annual mammography**

** Effective August 2016, members can self-refer to any participating TRICARE provider for annual mammograms and routine annual eye exams. It is the member’s responsibility to confirm the provider’s acceptance of TRICARE reimbursement.

Note: If you receive healthcare services that are not authorized by USFHP, you will be covered under the Point of Service (POS) benefit. (Emergency services are an exception.) See your USFHP Member Handbook or call our Member Services for more information.

Please contact our Member Services team for a list of providers to whom you may self-refer.

Referral Network
Your PCP will refer you to specialists and other medical professionals who are also connected with the Plan. We call this group the “referral network.” This system ensures better communication. It also ensures good coordination of care among your providers. If the specialty care you need is not available within this network, your PCP will refer you elsewhere. When both your PCP and the Plan authorize you to get care outside of the referral network, it is covered by the Plan.

About Referrals to Specialists

  • Your referral must be approved by the Plan. A referral authorization will be mailed to you and to the referring provider.
  • Referrals are valid only for the diagnoses indicated. They also are valid only for the services indicated.
  • Referrals have an expiration date. You cannot use them after that date, no matter how many visits are indicated. Keep track of the referral’s expiration date.
  • Referrals are for limited numbers of visits. It is very important that you keep track of the number of visits authorized. Also keep track of how many times you have seen the specialist.
  • Sometimes you need more visits with the specialist than those authorized by your referral. In that case, you must get another referral for the extra visits.
  • Sometimes the specialist wants you to see another specialist or get other services. You must first get authorization from your PCP.
  • Plan authorization is required for certain referrals. Some medical services have a limited benefit. Examples are oral surgery and sleep studies. These types of services need to be reviewed first to make sure that they are covered by the Plan. Suppose you are referred to a provider or facility that is outside the network. The referral must be reviewed for authorization. The Plan will see if that particular service could be provided inside the network. If authorized, you will receive your copy of authorization in the mail. It typically will arrive in 7 to 10 business days. Important: USFHP benefits apply only to covered services that are provided by your PCP or authorized in advance by the Plan.
  • If your referral is denied, you will receive a denial letter. It will give alternative recommendations and a description of the appeal process.
 

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