US Family Health Plan Referral Process

The new referral process begins with dates of services starting 10/1/2023.

Non-Participating Specialist: No later than 10/1/2023 for referrals to non-participating providers. Participating Specialist: Referrals through ProAuth to participating providers will be allowed at a later announced date. For referrals to participating providers please see ‘How does a provider submit a referral’ below.

Referrals have been required for USFHP and is included in the member and provider handbooks. The change is as of 10/1/2023 the referral must be submitted to MPHC based on new TRICARE reporting requirements.

Indicate the referring or ordering provider’s information in the section titled Name of referring provider or other source (Item 17 & 17b of the CMS-1500 paper claim form or the 2310A Referring Provider Loop, segments NM101 using qualifier DN or DK, NM103-NM105 [Name], NM108 using [XX] qualifier, and NM109 [NPI] of the 837P electronic claim) as indicated below.

All claim submissions for referred care require the referring provider be billed on the claim. If the referral is not submitted on the claim (box 17 or electronic equivalent) it will be considered ‘self-referred’. The POS Benefit cost share will apply and RARC code N212 "Charges processed under a Point of Service benefit" will be appended.

PCP or Specialist (specialist cannot self-refer but may refer to another specialist)

If a benefit requires a referral (as listed in the benefits and eligibility portal) and the beneficiary chooses to get care without a provider referral, the service will be considered a self-referral and the POS cost share will apply. The following services do not require a referral in order for the Standard Prime Benefit level to apply:

-Life-threatening emergencies
-Urgent Care
-Any Inpatient Services
-Annual physicals and preventative care
-OB/GYN Services (routine and specialty visits) from a Participating Provider
-Physical, Occupational, or Speech Therapies
-Orthotics and Prosthetics
-Durable Medical Equipment and Medical Supplies
-Wigs/Hairpieces
-Home Health/Hospice
-Ophthalmology/Optometry (routine and specialty visits) from a Participating Provider
-Office based Mental health care from a Participating Provider
-POS Exempt services as listed in the benefits and eligibility portal
-Services provided by the Primary Care Provider (PCP) (or covering provider/midlevel within the PCP Office)

Referrals to Participating Specialist
Referrals to participating specialist may be submitted directly to the participating specialist. The referral does not need to be submitted through ProAuth at this time. The in-network specialist will submit your referral information on their claims to Martin's Point.

Referrals to Non-Participating Specialist
Referrals to non-participating specialists will need to submit referrals through ProAuth, our online referral and authorization portal. Instructions for how to submit a referral for a non-participating specialist referral, please go to https://martinspoint.org/For-Providers/Tools/ProAuth-Documentation.

Martin's Point must adhere to TRICARE timeliness policies and regulations such that the maximum turnaround is 2 business days.

Referrals to Participating Specialist
Referrals to participating providers will be considered approved upon the referral being ordered.

Referrals to Non-Participating Specialist
Status of the referral will be available for Providers to view in ProAuth immediately after entry.

Members will be able to view their referral notifications in the member portal.

Participating Specialist
Referrals to participating providers will be considered approved upon the referral being ordered. Please reach out the PCP for a referral if you don’t have one on file. If you are unable to get a referral prior to service, the service will be considered ‘self-referred’ and the POS cost share will apply unless it is an exclusion listed above. See ‘How do I know if a referral is needed for this beneficiary?’


Non-Participating Specialist
Please reach out the PCP for a referral if you don’t have one on file. If you are unable to get a referral prior to service, the service will be considered ‘self-referred’ and the POS cost share will apply unless it is an exclusion listed above. See ‘How do I know if a referral is needed for this beneficiary?’

Authorization: Is a determination if the service is medically necessary and a covered benefit.

Referral: A referral is a request for specialty care. It is not a determination of medical necessity. A referral does not replace authorization or coverage requirements.

Approved referrals are used to apply the in-network/contracted co-pays and cost shares. When a referral is denied, the member has the option to use their point-of-service (POS) benefit and the denied referral will be used to apply the POS deductible and cost shares.

No – ProAuth is the appropriate submission tool for referrals.

Any physician/or mid-level who doesn’t provider primary care.

Yes - we will accept referrals retrospectively. The referral will have to be received within 120 days of the date of service.

To avoid member cost share implications, we ask providers to give best effort to submit referrals in advance. To ensure timely claims processing and best member experience, prospective referrals are the best approach.

Providers (participating/non-participating) should make sure that they have access to ProAuth and if not to reach out to their MPHC Provider Portal local administrator before the implementation date.

Participating Providers:
All claim submissions for referred care require the referring provider be billed on the claim. If the referral is not submitted on the claim (box 17 or electronic equivalent) it will be considered ‘self-referred’ and the POS Benefit cost share will apply.

Non-Participating Providers:
Providers who have an authorization approved in-network to a non-participating provider will not have to resubmit through ProAuth. The authorization will be used in lieu of the referral through the end date of the authorization.

No, the referral must be submitted by a provider. If a member chooses to receive care without a referral the service will be considered, ‘self-referred’ and Point of Service cost share will apply.