Referral for treatment

Getting care from a primary care physician

Your primary care physician (PCP) is a physician who meets state requirements and is trained to provide basic medical care. 

You must choose a primary care physician to provide and manage your care. A PCP can be a Family Practitioner, General Practitioner, Internal Medicine Pediatrician provider, and a specialist upon request. You may choose a specialist as your PCP if the specialist agrees to provide all the services that PCPs traditionally provide. 

To request for your specialist to be your PCP, contact Blue Shield of California Promise Health Plan Medi-Cal Member Services. A clinic, such as a Federally Qualified Health Centers (FQHC), may be your PCP as well.

Our plan’s PCPs are affiliated with particular medical groups. When you choose your PCP, you are also choosing the affiliated medical group. This means that your PCP will be referring you to specialists and services that are also affiliated with his or her medical group.

You will get your routine or basic care from your PCP. Your PCP can also coordinate the rest of the covered services you need. These services include:

• X-rays
• Laboratory tests
• Therapies
• Care from doctors who are specialists
• Hospital admissions
• Follow-up care

Getting care from a specialist

In most cases, you must see your PCP to get a referral before you see any other healthcare providers or visit a specialist. A specialist is a doctor who provides health care for a specific disease or part of the body. There are many kinds of specialists. Here are a few examples:

• Cardiologists care for patients with heart problems
• Oncologists care for patients with cancer
• Orthopedists care for patients with bone, joint, or muscle problems
   

When you need specialty care or additional services your PCP cannot provide, he or she will give you a referral. Once your PCP’s medical group has approved this referral, you can make an appointment with the specialist to receive the treatment you need. The specialist will inform your PCP upon completion of your treatment or service so your PCP can continue to manage your care.

Please note, you may self-refer to an obstetrical and gynecological (OB/GYN) specialist within your contracting medical group or Independent Provider Association (IPA) for a routine pap smear, pelvic exam, and annual breast exam.

To receive certain services, your PCP will need to get approval in advance from the plan, or, in some cases, your PCP’s affiliated medical group. This advance approval is called “prior authorization.” For example, all non-emergency inpatient hospital stays require prior authorization. Learn more about prior authorizations.
 

Services you can get without getting a referral from your PCP

In most cases, you will need approval from your PCP before seeing other providers. This approval is called a referral. You can get services like the ones listed below without first getting approval/referral from your PCP:

• Emergency services from network providers or non-network providers
• Urgently needed care from network providers
• Urgently needed care from non-network providers when you can’t get to a network provider (for example, when you are outside the plan’s service area).
• Kidney dialysis services that you get at a Medicare-certified dialysis facility when you are outside the plan’s service area. (Please call Member Services before you leave the service area. We can help you get dialysis while you are away.) 
• Flu shots, hepatitis B vaccinations, and pneumonia vaccinations, as long as you get them from a network provider.
• Routine women’s health care and family planning services. This includes breast exams, screening mammograms (x-rays of the breast), pap tests, and pelvic exams, as long as you get them from a network provider.
• Additionally, if you are eligible to receive services from American Indian health providers, you may see those providers without a referral. 
   

If you have any questions about referrals or prior authorizations, contact your PCP or PCP’s affiliated medical group. You can also call Member Services. The call is free.

 Phone: Los Angeles: (800) 605-2556 (TTY: 711), 8 a.m. to 6 p.m., Monday through Friday

 Phone: San Diego: (855) 699-5557 (TTY: 711), 8 a.m. to 6 p.m., Monday through Friday

In addition, the Blue Shield of California Promise Health Plan Nurse Advice Line can also assist with your medical questions.

 Phone: (800) 609-4166 (TTY: 711), 24 hours a day, 7 days a week.

For life or limb-threatening emergencies, always call 911 or your local emergency services.