CurrentFlorida BluePolicy N/A

Specialist referral visit limits for BlueMedicare HMO

This document governs the number and handling of specialist referrals for BlueMedicare HMO Medicare Advantage members and responsibilities of primary care physicians coordinating care.

Policy Summary

PayerFlorida Blue

PolicySpecialist referral visit limits for BlueMedicare HMO

Policy CodePolicy N/A

Change TypeUpdate to referral limits

Effective DateN/A

Next Review DateN/A

Key ActionPrimary care physicians must coordinate care and submit referrals for specialists; services without required referrals or authorizations will not be covered.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6maximum specialist referrals allowed

180specialist visit timeframe (days)

0out-of-network coverage

Referral and Network Coverage Rules

Referral and network criteria

Referral and network rules for BlueMedicare HMO Medicare Advantage members.

Members are allowed up to six specialist referral visits.

Members must visit the specialist within 180 days (applies to oncology and hematology).

Primary care physicians (PCPs) are responsible for coordinating access to all medical care and must submit referrals for specialists, including when the specialist is within the same multi-specialty group.

If an authorization or referral is required but is not on file, services will not be covered.

Providers can verify referrals online through Availity at availity.com.

Policy Summary

PayerFlorida Blue

PolicySpecialist referral visit limits for BlueMedicare HMO

Policy CodePolicy N/A

Change TypeUpdate to referral limits

Effective DateN/A

Next Review DateN/A

Key ActionPrimary care physicians must coordinate care and submit referrals for specialists; services without required referrals or authorizations will not be covered.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Provider Responsibilities and Authorization

Prior Authorization

PCP referral submission and verification requirement

Primary care physicians (PCPs) for BlueMedicare HMO members must coordinate access to all medical care and submit referrals for specialist visits, including when the specialist is within the same multi‑specialty group. If an authorization or referral is required but not on file, services will not be covered. Providers may verify referrals online through Availity at availity.com.

PCPs must submit referrals for specialists within the same multi‑specialty group.
Services without a required authorization or referral on file will not be covered.
Referral verification is available via Availity (availity.com).

Network and Specialist Definitions

Out-of-network coverage

General out-of-network coverageBlueMedicare HMO does not cover out-of-network benefits except as specified

Exceptions - emergency and urgent careOut-of-network services are covered for emergency and urgent care

Exceptions - dialysis servicesOut-of-network dialysis services are covered

Exceptions - specifically authorized servicesOut-of-network services specifically authorized are covered

Exempt specialists (no referral required)

Women's health (routine/preventive)No referral required for routine and preventive women's health visits

Chiropractic careNo referral required for chiropractic care

PodiatryNo referral required for visits to podiatrists

Behavioral healthNo referral required for behavioral health visits

DermatologyNo referral required for visits to dermatologists

OpenPayer

Specialist referral visit limits for BlueMedicare HMO

Referral and Network Coverage Rules

Referral Limits and Coding Notes

Provider Responsibilities and Authorization

Network and Specialist Definitions