Specialist referral process for BadgerCare Plus members

Here's what you need to know

As a member, you are required to choose a primary care provider (PCP) or a primary clinic. And in most cases your medical care can be provided by your PCP. However, you may need to see a specialist for certain types of care.

Seeing a specialist

If you need to see a specialist, you may need a written referral from your doctor. It's needed when your PCP recommends services by another provider who isn't part of your primary clinic or is a non-plan provider. This helps ensure you get the right care.

When a written referral is needed, your PCP fills out our request form and submits it to us for review and approval.

A verbal request does not take the place of a written request form. Requests to see non-plan providers must be approved by us before you receive services. Approval could take up to 14 business days to complete.

Referral limits

Your referral request could be limited to a specific number of visits or time period and expires when either limit is reached.

For example, you may receive a referral for three visits to a specialist over the next three months. If only two visits were used and three months have gone by, the remaining visit is not approved. Or, if three visits were used in two months’ time, the referral is not valid for the remaining month.

Before seeking additional health care services, call your PCP to ask for another referral. You should follow the same process when workers’ compensation, motor vehicle insurance, etc. may be involved.

You must wait to receive written notice that your request has been approved before seeing a provider.

Other insurance

If your plan with us is your secondary insurance, you are always required to follow the rules of your primary insurance. If you don't follow the rules of your primary insurance, you may need a referral or claims may be denied.

If you need urgent or emergency care, a referral is not needed. But any follow-up care you need must be from your PCP or another plan provider. If you are seeking follow-up care by a non-plan provider, it must be approved by us before receiving services.