Referral Process for Primary Care Network
Within the Primary Care Network (PCN) program, the primary care physician (PCP)
is the care manager, who is responsible for referring, authorizing, ordering,
arranging and coordinating all health-care needs. The PCP should refer patients
to participating providers (physician specialists, hospitals and other
health-care professionals who have agreed to work with the PCN, group and PCP
in delivering health care).
After discussion with the patient, the PCP decides when a specialist is needed
and, with input from the patient, which specialist will be used. USAble or the
employer's group administrator sends the appropriate provider directories to
PCN physicians for use in making referrals. The PCP selects the specialist from
the plan's network.
When a PCP sends a patient to a specialty provider, the PCP must complete a
referral form. Referral forms are not required for the following:
Normal newborn services
Services rendered by a PCP backup physician
Durable medical equipment
The Script Pad Referral Process provides an authorization process for a
participating PCP to refer a member to a provider for services outside the
You may download a Referral Form here in PDF (portable document format). This
file will allow you to print a copy for completing off-line.
Referral Authorization Process
1. The member's PCP or the PCP's approved covering (backup) physician is
required to authorize services performed outside the PCP's office prior to the
delivery of services.
2. The member is responsible for obtaining a Referral Authorization from the PCP
prior to receiving services.
3. The referral form should be filled out completely by the PCP and given to the
member as verification that the PCP has authorized services.
The following information must be included on the Referral Authorization Form:
Member name and ID number
Reason for referral
Date span of services
Number of visits
PCP's five-digit USAble provider number
4. The PCP should place a copy of the referral in the member's medical chart or
maintain a written record of the referral for future reference.
5. The member should present this referral form when making the first provider
6. Billing information:
When covered services are rendered in accordance with the current referral
form, services provided by the participating provider do not need additional
If the specialist determines that another specialist needs to examine or treat
the member, the PCP must be consulted. Referrals are accepted only from the PCP
or an approved covering (backup) physician.
Referral services are subject to member eligibility and the benefits available
through the member's plan. Therefore, a referral authorized by a PCP should not
be considered as a guarantee of payment.
Specialty, hospital and ancillary providers need to enter the PCP's five-digit
provider number in Field 23 on the CMS-1500 claim form (formerly HCFA-1500).
This number notifies USAble Administrators that the patient has not
To obtain additional referral forms, the physician should call the
customer-service number on the member's ID card.
Referrals to out-of-network (OON) providers require prior notification to USAble
Administrators. Prior notification can be obtained by faxing the Script Pad
Referral Authorization Form to USAble Administrators at (501) 378-2965 or by
P.O. Box 1460
Little Rock, AR 72203
Please note the following:
OON referrals must be made in advance of services rendered.
OON referrals must be requested by the member's PCP or an approved covering
Emergency care does not require a referral.
Follow-up care does require a referral if not provided by the PCP.
OON referrals should be made by faxing a copy of the Script Pad Referral
Authorization Form to USAble Administrators at (501) 378-2965. In addition, a
copy of the Script Pad Referral Authorization Form should be provided to the
member as verification that the PCP has authorized the services.
Services referred to and provided by an OON provider may not be eligible for
reimbursement or may be covered at a reduced benefit level.
All referrals expire at the end of three months unless otherwise specified by
the PCP, and the PCP will need to evaluate the need for continued referral.
Services beyond those initially requested by the PCP may not be eligible for
reimbursement unless authorized in advance.
Under most plans, self-referrals by patients themselves will either be
non-covered, or the payment to the specialist will be reduced significantly
based on the benefit plan of the group. Some plans authorize self-referrals,
which are eligible for coverage.