Referral Submission and Inquiry Guide Independence Blue Cross offers products directly, through Page its 1 subsidiaries of 10 Keystone Health Plan East and QCC Insurance Company, and with Highmark Blue Shield independent licensees of the Blue Cross and Blue Shield Association.
The referral submission and inquiry transactions allow providers to submit new referrals for Independence Blue Cross (IBC) members and search for referrals that were submitted by a provider or referred to that provider. Note: Several changes related to referral transactions are effective October 25, 2013, including: All medical and OB/GYN referrals will be submitted and queried through a single transaction on the NaviNet web portal. Primary care physicians and OB/GYN offices submitting referrals will no longer be able to fax referrals to specialists or facility providers. Referrals will not be written to the Ref/Auth log. Providers will need to use the Referral Inquiry transaction to look for a submitted referral. NaviNet will purge incomplete and completed referrals from the Ref/Auth log on October 25. Providers will have to use Referral Inquiry to look up completed referrals. Referral Submission transaction To submit a new referral for an IBC member, select Independence Blue Cross from the Plan Central drop-down menu. Next, select Encounters and Referrals from the Plan Transactions menu, and then Referrals. Then select the Create New Referral button. Page 2 of 10
When submitting a referral, you will need to indicate the date of the referral in the Effective Date field. Referrals can be issued for the current date or up to 90 days in the past. 1000001111 You are required to enter the Effective Date and Member ID on the Patient Search screen. Only members with active IBC coverage will be returned in the search results. Tip: Entering the patient s last name, first name, and date of birth will narrow down your search. If the member search returns multiple members, the Patient Search Results screen will list those members and indicate if their plan requires a referral in the Referral Required? column. Select the appropriate member record by clicking on the row to bring up the Create New Referral screen. Page 3 of 10
If the member search returns only one member whose product requires a referral, the Create New Referral screen will display automatically. Page 4 of 10
On the Create New Referral screen, you will need to select a Service Type from the provided drop-down menu: 1000001111 Next you will need to select a Place of Service from the provided drop-down menu. The Referral Information link open a screen with two tabs (Medical Referrals and OB/GYN Referrals), which provide additional instruction on referral submission requirements. Page 5 of 10
Next you will need to complete the Diagnosis field, and at least one diagnosis code must be entered. You may either enter a diagnosis code or part of the description in the text box. The drop-down menu that appears will provide both the code and description of all active diagnoses that match the text or code you enter. You can enter up to four diagnosis codes. Once a diagnosis code has been selected, a delete button will appear under Actions. Clicking the delete button will remove the corresponding diagnosis code. In the Referred From Provider field, begin to type the provider name, NPI, or corporate ID number for results to display in the box. You can also type the group name, group NPI, or corporate ID number of the provider group associated with your NaviNet profile. Next you must complete the Referred To section. Search for a participating facility or provider by selecting the Search button. Page 6 of 10
Once you ve selected Search, the Facility/Provider Search screen will appear: Facility Search. If you are looking for a facility, enter the Facility Name or Facility NPI in the Facility Search section. You can also enter the Specialty, City, and/or ZIP Code to narrow the search. Provider Search. If you are looking for a physician, enter the provider s Last Name and at least one of the following fields: First Name, Billing Provider NPI, Billing Provider Number, Specialty, City, or ZIP Code. Once you ve entered your criteria, select Search. NPI NPI Select the appropriate facility or provider by clicking on the row. Page 7 of 10
Once you ve made your selection, you will be returned to the Create a Referral screen. There, you will have the option to select Submit or Cancel to complete the process. If you select Submit, the Referral Details screen will appear and summarizes the details of your referral submission. 1000001111 At this point, you can exit the Referral Submission transaction screen or select Create Another Referral to begin another submission. To print a copy of the referral, select Print in the top right corner of the screen. Referral Inquiry transaction For a referral inquiry, select Encounters and Referrals from the Plan Transactions menu, and then select Referrals. Page 8 of 10
Begin a referral search for one of the following: To view referrals submitted by your practice or facility, select Referred From. To view referrals submitted to your practice or facility, select Referred To. Corp ID Next enter dates for the referral you are inquiring about in the From and To fields (calendar icons are available to assist with your selection). You can search for referrals submitted or received up to one year from the current date. Entering a Referral Number is optional and can narrow down the search results. Select Search after entering your criteria. If multiple search results are found, they will be displayed as shown below, sorted by Member ID in ascending order. ELIZABETH BLAKE (1000001111) ELIZABETH BLAKE (100000111) The Search Referrals field allows you to refine your search from the Search Results screen. You can enter any data displayed on the screen (e.g., Referral Number, Patient, Member ID, Status, Referred From, Referred To, Effective Date). From the Search Results screen, an individual referral can be viewed by selecting the record. Page 9 of 10
If only one referral is found, you will not see the Search Results screen; instead you will see the Referral Details screen for the individual referral found. 1000001111 In addition to the patient s name, all referrals will display an Active or Expired status, the referral number, and the referral effective and expiration dates. Each referral will indicate the Referred From provider who initiated the referral as well as the Referred To provider. To print a copy of the referral, select Print in the top right corner of the screen. NaviNet is a registered trademark of NaviNet, Inc., an independent company. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans. Page 10 of 10