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Sometimes you need health care your Primary Care Provider can't give you. You may need care from a specialist or a hospital. To see a specialist or for treatment at a hospital, your Provider must authorize (or okay) the care, and give you a "referral." (A referral is a request from your Provider to another doctor or to the hospital for health care services or treatment you may need). Your Provider will start the referral process but you MUST get a referral BEFORE you get specialized health care services or treatment.
Routine referrals take up to five (5) business days to process (business days are Monday through Friday), but may take longer if more information is needed from your Provider. In some cases, your Provider may ask to "rush" your referral. Expedited (rush) referrals may not take more than three (3) calendar days. Please call Care1st Health Plan if you do not get a response by these times.
But if you need to see an Ob/Gyn or need to receive emergency or urgent care, you do not need a referral. Emergency or urgently needed services are covered 24-hours a day, seven (7) days a week in L.A. County and San Diego County and also anywhere in the United States, Canada, and Mexico. Referrals are never needed for emergency or urgently needed services or Ob/Gyn care.
If a referral is not approved, you will receive a letter from your Provider or Care1st Health Plan explaining why the referral was denied. If you do not agree with the explanation given, you may file a complaint. For information on how to file a complaint, turn to the "Complaints: What should I do if I am unhappy?" section of the Member Handbook.
You may need to see a specialist (or another qualified health care professional) for a long time if you have a chronic disease (such as diabetes or asthma), a life-threatening condition (such as HIV/AIDS) or a disability.
This is called a "standing referral". (A standing referral is made to a specialist who is in Care1st Health Plan’s network or who is with a contracted specialty care center). If Care1st Health Plan does not have a qualified specialist in the network, we will send you to a specialist outside of our network.
A standing referral needs an approval by Care1st Health Plan. You can ask your Provider for a standing referral, or your Provider can ask Care1st Health Plan for a standing referral.
Care1st Health Plan must decide on your request for a standing referral within three (3) business days (business days are Monday through Friday). Once you have a standing referral, you will not need permission for each visit with the specialist.
Your specialist will develop a treatment plan for you that will show how often you need to go to visit the specialist. Once the treatment plan is approved, the specialist will coordinate the care you get. This specialist will be authorized to provide health care services the same way your Primary Care Provider would give you.
Call Blue Shield of California Promise Health Plan at (866) 820-6009 (Los Angeles County) or (855) 699-5557 (San Diego County) if you have questions about your benefits. The call is free. We are available Monday through Friday, 8:00 a.m. to 6:00 p.m. For emergencies, you can call this number 24 hours a day, 7 days a week.