Referrals

What happens when you’re referred to a specialist?

Referrals to an In-Network provider

No referral* is necessary when you’re referred to an in-network specialist. Go to the Provider Search and select your plan to see specialists in your network, or contact Customer Service for assistance.

*This does not apply to Health Tradition CarePlus members. Health Tradition CarePlus members should refer to their benefit summaries for specific benefit details, which can be found in their Maddy Portal account at MaddyPortal.com. To see if you are a Health Tradition CarePlus member, reference your ID card and look for the Health Tradition CarePlus logo.

Referrals to an Out-of-Network provider

Health Tradition offers many plan choices, with different provisions for out-of-network services. See your plan’s Summary of Benefits and Coverage or Certificate of Coverage.

• Health Tradition for Employer Groups and 65Plus members:

Referrals must be approved by Health Tradition before the member receives the covered services requested by an in-network healthcare provider. Preventive services are not covered out-of-network.

• Health Tradition Point of Service (POS) for Employer Groups plan members:

To receive coverage at the higher in-network benefit level for healthcare services received from out-of-network providers, a member must obtain a referral from an in-network provider.

However, Health Tradition must approve the referral before the covered services listed in the referral are eligible for payment at the in-network benefit level. Coverage at the in-network benefit level is limited to the type, frequency and duration of the healthcare services approved in the referral.

Refer to your schedule of benefits and coverage or contact Customer Service.

• Health Tradition CarePlus:

Referrals must be approved by Health Tradition before the member receives the covered services requested by an in-network healthcare provider. Preventive services are not covered out-of-network.

In-Network Provider

Health Tradition: No referral is required when referring to an in-network specialist.

Health Tradition CarePlus:  This plan design DOES require a referral to In-Network specialists.*

*NOTE: Audiology, Behavioral Health, Chiropractic, Dental, Dietician, Home Nursing Care, OB/GYN, Ophthalmology, Optometry, Oral Surgery and Rehabilitation Medicine (OT, PT, ST) services with In-Network providers DO NOT require a referral.

Out-of-Network Provider

A referral is required when referring to an out-of-network provider. Out-of-network provider referrals are approved in limited circumstances.

The referring provider will submit a referral request to Health Tradition for approval prior to a member seeking services with a specialist. Any in-network provider can submit a Referral request.

Please refer to the Provider Forms section for the appropriate Referral Form.

Referral Process

The Referral form is available as a fillable PDF document on the Maddy Provider Portal in the Authorization & Referrals section and on the Health Tradition website at our Provider Forms page.

• The Referral form will need to have all required fields completed and faxed to the fax number on the form.
• The Referral request will be reviewed and approved or denied within 15 calendar days.
• The decision notification will be sent to the member, the referring provider and the referred-to provider.

If a visit with a specialist occurs without an approved referral all services related to that visit are not covered and the member is responsible for all charges.