Referrals

The following questions and answers offer a glimpse of what you can expect as a Blue Cross Blue Shield of Massachusetts member. If you don't find the answer you are looking for, contact Member Service at the number on the front of your ID card.

When you and your primary care provider (PCP) determine that you need specialized care, your PCP will "refer" you to a specialized provider from our trusted team. A referral is required by your HMO health plan before the plan will cover certain services. It’s important that the referral comes from us—not only because your plan requires it, but because your PCP, as the center of your care, needs to be involved and aware of the care you’re receiving, and to coordinate with you and your specialist on an ongoing basis.

Your PCP knows your history and overall health, so he or she is best qualified to help you decide if you should see a specialist. Even if your health plan doesn’t require a referral, your PCP may want to evaluate your care needs before you see a specialist, in order to better coordinate your care. We’re committed to making sure you get the right care, at the right time, in the right setting—especially if you need to see a specialist.

Contact your PCP’s office to discuss your health situation. Together, you can decide if you need to see a specialist. If you do need to visit a specialist, your PCP will help you choose the most appropriate doctor for the care you need. Be sure to have this conversation before you visit a specialist. If you see a specialist without a referral, you may be responsible for the entire bill (not just the copay or deductible).

We rely on a trusted network that includes a wide range of specialists to carry out your treatment plan. By referring you to specialists we know well, you, your specialist, and our group can work together to ensure you get high-quality, timely, and effective care.

Please note that not all of the specialists in your health plan’s network are a part of our group. It’s very important to always discuss your clinical condition and concerns with your PCP to determine together if a specialist visit is needed and which doctor is best for you.

Because your PCP coordinates your care, you should always let our group know whenever you seek treatment of any kind. There are certain instances, however, when you don’t need a referral from your PCP in order to receive coverage from your health plan, including cases when you seek emergency medical care, covered annual gynecological exams, and other services required as result. For further details about the specific cases that don’t require a referral, please call Member Service at the number on the front of you
ID card.

As the coordinator of your care, you should always contact your selected PCP about your emergency room visit. He or she will determine the best coordinated follow-up care for you.

There are several ways to learn about your plan's referral requirements: check your subscriber certificate provided by your health plan or call Member Service at the number on the front of your ID card. It's essential that you fully understand your plan's referral requirements, because if you don't get a required referral prior to receiving non-emergency care, you may be responsible for the entire bill (not just a copayment or deductible).

If you have a medical question about a referral, just call us. If you need information about whether a service is covered or requires a referral by your health plan, please call Blue Cross Blue Shield of Massachusetts’s Member Service at the number on the front of your ID card.

As a general rule, Blue Cross Blue Shield of Massachusetts will not pay for care from a specialist without a referral from your PCP. However, the following are instances when you do not need a referral:

  • Emergency care.
  • For HMO Blue and Blue Choice members, covered services from a network obstetrician, gynecologist, or certified nurse midwife, or gynecological services and other women's health services from a network family practitioner.
  • A routine eye exam every two years for HMO Blue New England and Blue Choice New England members.
  • An annual routine eye exam for HMO Blue and Blue Choice members.
  • Blue Choice members have the option to self-refer at a higher level of out-of-pocket costs for any other covered service.