TMPPM 2008 > Provider Information > Managed Care > PCCM

7.5.19.8 Claims for Specialist Services

Specialists may bill for health-care services provided to PCCM clients if the patient was referred by the client's primary care provider. To indicate a referral from the client's primary care provider, the primary care provider's name and provider identifier must be included in the Referring Physician field (boxes 17 and 17A) on the CMS-1500 claim form. A referral is not required if a specialist is providing a service that does not require a referral from a primary care provider.

Reimbursement for specialists is based on the current Medicaid fee-for-service rates.

Refer to: "Referrals" and "Self-Referred Services" .