Referrals

When members enroll in BCBSND insurance coverage they select a network of care providers in which to receive care. If a member goes outside the chosen network for covered care, that service will be reimbursed at the out-of-network benefit level.

The exception is when a type or level of service is not available within the member's chosen network. In that case, a health care provider can request an authorized referral to receive in-network benefits.

Plans that require network referrals 

  • BlueChoice
  • SelectChoice
  • Medicaid Expansion

Referral guidelines

You can get the support you need to process claims accurately and in a timely manner by using the following guidelines. 

  • The referring network should communicate all referrals in the BCBSND provider portal using the instructions below.
  • The requesting provider is responsible for communicating the referral status to the BCBSND member in a timely manner.
  • Requests should be for medically appropriate services not available in the member's chosen network.

Note: The Medicaid Expansion line of business has a different referral process than the commercial line of business. Please refer to the appropriate provider manual for additional guidance.

  • To view the referral details for the BCBSND commercial line of business, review section “Authorized (Network) Referrals” of the provider manual.
  • To view the authorized referral details for the BCBSND Medicaid Expansion line of business, review section “Referrals for Out-of-Network Services” of the Medicaid Expansion provider manual.

Authorization of referrals

Referrals are requested in Availity Essentials. 

After logging in, go to the Patient Registration drop-down menu.

  • Choose Authorization & Referrals.
    •  Follow the guidance outlined in the appropriate provider manual for details on how to submit the request.

Referrals may be denied for several reasons, including the availability of service options in network. Provider or member convenience or preference is not a valid reason for a referral.

(Your organization's plan administrator determines who has access to this feature.)

Who's my organization's plan administrator? 
To find out, select My Administrator from the portal's home page.