Currentblue cross blue shield - michiganPolicy N/A

PPO Out-of-Network Referral Form / Process

Governs referrals for PPO members to non-PPO practitioners, facilities, ancillary providers, or laboratories and explains member/facility responsibilities and time limits for referrals.

Policy Summary

Payerblue cross blue shield - michigan

PolicyPPO Out-of-Network Referral Form / Process

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain a referral for out-of-network services when medically necessary and not reasonably available in-network; referrals are valid up to 60 days and cover services within one year.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

60 daysreferral valid up to

1 yearservices must be performed within

7-digitPPO PIN (claim field)

10-digitNPI required

Out-of-Network Referral Coverage Criteria

Covered when ALL of the following conditions are met:

Service must be medically necessary and not reasonably available within the TRUST network

Referral is completed by the PPO practitioner, facility or laboratory

Referral is valid (see time limits) and authorizes care to a non-PPO practitioner, facility, ancillary provider, or laboratory

Member responsibilities for in-network cost sharing remain if the member contract requires in-network deductibles, coinsurance, or copays

Financial responsibility if provider not in BCBSM network

Policy Summary

Payerblue cross blue shield - michigan

PolicyPPO Out-of-Network Referral Form / Process

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain a referral for out-of-network services when medically necessary and not reasonably available in-network; referrals are valid up to 60 days and cover services within one year.

SourceLink

On This Page

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Claim Form Identifiers and Referral Time Limits

Claim form identifiersmixed

PIN (7-digit)	PPO referring practitioner/laboratory PIN to record in CMS-1500 field 10D; record PPO referring practitioner/facility/laboratory PIN in the 'Treatment authorization' field on UB-04
NPI (10-digit)	Record 10-digit NPI in CMS-1500 field 17b and record 10-digit NPI in field 56 on the UB-04 claim

Referral time limits

Referral validity periodReferral is valid up to 60 days from the date of referral

Service coverage windowReferral covers services performed within one year of the date of referral

Retroactive referralsRetroactive referrals will not be approved without documentation in the member's medical record

Out-of-Network Referral Requirements and Time Limits (Provider Responsibilities)

Note

Out‑of‑Network Referral: When to Refer, Time Limits, and Documentation

Refer PPO members to non-PPO practitioners, facilities, ancillary providers, or laboratories only when the service is medically necessary and not reasonably available within the TRUST network. Ensure the referral date is recorded; referrals are valid for up to 60 days from the date of referral and cover services performed within one year. Do not submit retroactive referrals unless supporting documentation is present in the member's medical record. Be aware that if the member’s contract includes in‑network deductibles/coinsurance/copays those member cost‑sharing obligations remain, and if the referred provider does not participate in any BCBSM network the member may be responsible for charges exceeding BCBSM payment.

Record the referral date on the referral form; referrals expire 60 days after the referral date.
Services must be performed within one year of the referral date to be covered under the referral.
Do not request retroactive referral approval without documentation in the medical record.
If referred to a non‑approved BCBSM facility, benefits are not covered (e.g., non‑approved outpatient mental health).
If referred provider is not in any BCBSM network, patient may be liable for amounts exceeding BCBSM payment.
Ensure practitioner identifiers are recorded as required (7‑digit BCBSM PIN digits 3–9 and 10‑digit NPI).

Key Definitions

Referral (out-of-network) definition

TermReferral (out-of-network)

DefinitionCompleted by the PPO practitioner, facility or laboratory when a member is being referred for services to a non-PPO practitioner, facility, ancillary provider or laboratory

Coverage conditionRequired when covered services are medically necessary and not reasonably available within the TRUST network

Retroactive referral

Retroactive referral policyRetroactive referrals will not be approved without documentation in the member's medical record

Action required for hospitalizationIf hospitalization is necessary, inform the referring PPO practitioner immediately and request a new referral

Claim attachmentAttach the yellow copy of the referral form to paper claims when submitting