Referrals, Empire Plan supplement - 2021 Administrative Guide

The Empire Plan does not include requirements for a primary care provider (PCP) to coordinate referrals for specialist care. Members may self-refer to any care provider for covered services and receive appropriate in-network or out-of-network benefits based on the network status of the care provider.

Anesthesia services

You will help ensure all covered anesthesia services rendered at your practice location are performed by participating care providers for as long as the Agreement is in effect.

Laboratory services

We only reimburse for laboratory services you are certified to perform through the Federal Clinical Laboratory Improvement Amendments (CLIA). You must not bill our members for any laboratory services if you don’t have the applicable CLIA certification.

Other services

If you determine a member requires treatment or services from another care provider, you must use reasonable efforts to refer them to a network care provider.