If you feel you need to see a specialist, such as a dermatologist or cardiologist, you should discuss this with your primary care physician to receive the necessary referral.
A referral to specialist care
There are many reasons why you should get a referral for specialist care from your primary care physician, including:
- Your primary care physician can make an initial diagnosis of your medical condition and direct you to the proper specialist as necessary.
- Your primary care physician knows your medical history and is responsible for the overall coordination of your care.
When you receive a referral from your primary care physician, your copay when you visit the specialist is the same as a visit to your primary care physician.
You will usually be referred to a specialist in your medical group or IPA. In addition to being less expensive (in most cases), specialists within the same medical groups or IPA have better access to your medical records and can more easily communicate with your primary care physician about your care.
If your primary care physician believes that you should see a specialist that is not in his or her medical group or IPA, you may be referred to a specialist elsewhere within our network. Your care will be covered in this case -- once Blue Shield authorization is obtained.
The Access+ specialist option
If you want to see a specialist for any reason then you may do so through the Access+ Specialist option -- without a referral. You may have to pay an additional or higher copayment at the time of this visit. For specifics regarding your Access+ Specialist benefits, please refer to your Evidence of Coverage (EOC) or Certificate of Insurance (COI).
If it's determined that you need to see this specialist on an ongoing basis, you or your specialist should contact your primary care physician who will then decide whether it is appropriate to give you a referral for specialty care. In this case you would pay your usual office visit copayment (outlined in your EOC or COI).
In any case, your Access+ Specialist will inform your primary care physician of the results of your examination or consultation and any test results. This information will be recorded in your medical record, to keep it complete and up to date.
Some services are not covered under the Access+Specialist option or can be provided through your primary care physician. Additionally, you may not need a referral for mental health and substance abuse care. Refer to your Evidence of Coverage (EOC) or Certificate of Insurance (COI) to get a list of services covered by this option.
Medical groups and IPAs that participate in the Access+ Specialist program are designated with an "A+" in Find a Doctor, in printed directories and on your Blue Shield ID card.