Both HMO Illinois and BlueAdvantageSM HMO offer members access to specialist care.
The need for specialty care is determined by you, the member, and your primary care physician (PCP). A female member's Woman's Principal Health Care Provider (WPHCP) may also make referrals for specialist evaluation or care needed for obstetric or gynecological conditions.
Decisions Regarding Medical Treatment
We believe the best people to determine your medical care needs are you and your PCP or WPHCP. You are encouraged to discuss all treatment options with your doctor to determine the best course of care, including referrals to a specialist. Through his or her role as the coordinator of your specialist care, your PCP can track and support your overall health, even when you are receiving services outside their practice. A referral is not needed for emergency room care, substance abuse treatment or routine vision care.
Note: Members of the Physicians Care Network, Inc. (PCN) do not need a referral for mental health care, which is coordinated directly with the behavioral health network provider. PCN members must call the number on the back of their ID card to locate a contracting mental health care provider.
General referrals are made within your medical group network. The referral is made for a specified number of visits or a specific time frame, up to one year.
Referral procedures are determined by each medical group and do vary. For example:
- Your PCP or WPHCP may need to consult his or her Medical Group/Independent Practice Association (MG/IPA) about treatments he or she recommends before issuing a referral.
- Some MGs/IPAs require you to present written referrals to specialists, while others may use computerized referral systems that eliminate this step.
- You must have a referral from your PCP before seeking care from a specialist.
- It may take a medical group up to five days to get referral care authorized.