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BCBSND News
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:
- DakotaBlue *
- Medicaid Expansion
General referral reminders:
- Authorized referrals do not guarantee payment of benefits.
- Referrals must be for medically appropriate and necessary services and are subject to conditions, limitations, and exclusions of the member’s benefit plan.
- In-network providers must not request referrals for services that are available through a network provider.
- Emergency services are reimbursed at the in-network level; referrals are not required.
Referral submission guidelines:
Please refer to the appropriate provider manual for additional guidance on how to submit a referral.
- To view the referral details for the BCBSND plans identified above *, review section “Authorized (Network) Referrals” of the provider manual.
- To view the authorized referral details for BCBSND Medicaid Expansion, review section “Referrals for Out-of-Network Services” of the Medicaid Expansion provider manual.
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.
