Out-of-Plan Referral Guidelines

Out-of-plan (OOP) referrals should be requested for BlueShield of Northeastern New York patients only when:

• The patient is outside his or her service area
• Participating providers in the area cannot provide the necessary services

Services must be requested by the patient’s primary care physician or participating specialty provider. A request form for OOP coverage is available here.

The following information is required:

• Office notes, consultation reports, diagnostic studies, and in-plan provider documentation that supports the need for the patient to be seen by an OOP provider
• OOP provider name (requesting provider, assistant surgeon, co-surgeon)
• OOP provider address
• OOP provider specialty
• Planned services CPT® codes, if applicable
• OOP provider assistant/co-surgeon information

Definitions:

Non-participating provider (NPP): A provider (e.g., facility, vendor, physician, or other clinician) who does not participate with any BlueCross/BlueShield plans; claims submitted by an NPP would process to the patient’s out-of-network benefit unless an out-of-plan referral is on file.

Out-of-network provider (OONP): A provider (e.g., facility, vendor, physician, or other clinician) who does not participate with the patient’s home plan, but does participate with the BlueCross/BlueShield plan in the provider’s local area. Claims submitted by an OONP will process to the patient’s out-of-network benefit unless an out-of-plan referral is on file.

Out-of-Network (OON) benefits: Coinsurance, copay, and/or deductible that the patient is financially responsible for when receiving services from a NPP or OONP. Typically, when a patient uses his or her OON benefit, he or she will incur higher out-of-pocket costs.