Referral Policy - Beth Israel Lahey Performance Network

Referral Authorizations and Policies

When referring a patient with an HMO Plan for specialty care consultations, payer plans often require a PCP referral authorization. This ensures that our patients are receiving the appropriate care at the right time and at the right place.

At Winchester PHO, our team works closely with specialists directly within our referral circle to coordinate care so that it’s as seamless and convenient to the PCP referring care, the patient receiving care, and the specialist rendering care. Often times, patients who are referred to specialists in the Winchester PHO’s referral circles (via a specialty referral), may be seen without the need for a PCP referral authorization.

Referral Process

Winchester PHO has developed several referral grids to help practices easily see when referrals will be needed. See the appropriate grid for guidance on whether a referral authorization is needed when the PCP or Specialist is a member of WinPHO or other LCPN providers if the patient is contracted with BCBS, HPHC or Tufts HMOs.

If you have any questions, please contact the Referral Mangaement Team at: (781) 756-2111, option2.

Practices are responsible for obtaining authorizations as needed for all other payer plans that are not part of the Winchester PHO contracts.

Notes:

HPHC Atrius POS plans need referrals even when a patient sees a WINPHO (or any LHS) specialist within a referral circle.
BCBS HMO Select Limited Plans – specialty services are NON-PAR if the specialist is not PRIMARILY AFFILIATED with BCBS in the WinPHO. Patients’ claim may be denied even with a referral authorization.
BCBS Anthem NH plans have separate referral guidelines. Please check patient benefits. Standard referral simplification rules do not apply.
TUFTS MEDICARE PREFERRED (a Medicare Replacement plan) may need an authorization from the PCP. Standard referral simplification rules do not apply.

Specialists who are in the WinPHO and participate in the contracted payer plans may see patients without the need for a PCP referral authorization.

Primary Care Providers who belong to the Winchester PHO and the greater Lahey Clinical Performance Network are part of the same referral circle and therefore may not need a PCP authorization.

If you have any questions, please contact the Referral Mangaement Team at: (781) 756-2111, option 2.

Notes:

HPHC Atrius POS plans need referrals even when a patient sees a WINPHO (or any LHS) specialist within a referral circle.
BCBS HMO Select Limited Plans – specialty services are NON-PAR if the specialist is not PRIMARILY AFFILIATED with BCBS in the WinPHO. Patients’ claim may be denied even with a referral authorization.
BCBS Anthem NH plans have separate referral guidelines. Please check patient benefits. Standard referral simplification rules do not apply.
TUFTS MEDICARE PREFERRED (a Medicare Replacement plan) may need an authorization from the PCP. Standard referral simplification rules do not apply.

Questions?

If you have questions, please contact

Central Referral Management Department

(781) 756-2111, Option 2

Note: If a specialist is non-participating, a different referral process is required. Providers who need to refer to a non-participating specialist should download and use this form.

Referral Authorizations and Policies

Referral Process

For Primary Care Providers - Outgoing Referrals

For Specialists - Incoming Referrals

Questions?

Central Referral Management Department

(781) 756-2111, Option 2