Can I receive payment for services provided if I am not the members designated primary care provider?
On occasion members may be confused and seek care from a provider that is not their designated PCP. This may occur with another physician within a group practice or with a provider in an entirely different practice. We understand this happens and we want you to know how we handle these circumstances. First, we would not deny payment for any claim solely based on the member having received services from a provider other than his/her designated PCP. As long as the provider is in our network, whether the member’s designated PCP or not, and the member was otherwise eligible for coverage, we would process the claim for payment. This is also the case for services provided by a participating referral specialist. We encourage members to use their designated PCP for the coordination of all services; however, as a practical matter we do not have a formal referral process and therefore would not deny payment for the services of any participating referral provider solely based on no referral from
