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Referral Request Process
Frequently Asked Questions for
Members of the Traditional and Flexible MIT Health Plans
This document contains information about referrals for
outpatient medical or surgical services only. For information
about using mental health benefits and services please
see the Blue
Cross Blue Shield of Massachusetts (BCBSMA) Managed Care
Behavioral Health Network FAQ. Please call Health Plans
Claims and Member Services at 617-253-5979 with any other
questions about benefits, coverage, or referrals.
What is a referral?
A referral is a request from a clinician to the MIT Health Plans to
approve services outside of MIT Medical. A clinician's suggestion that
a patient may need outside services is not a guarantee of health plan
coverage. If your clinician suggests outside services, you may want to
ask him/her if they are submitting an official referral request on your
behalf.
When is a referral made?
A clinician makes a referral request when he or she determines that
a patient needs medical services that are not available at MIT Medical.
How do I know what services are available at MIT Medical?
Services at MIT Medical are listed on our Services page
. You may also contact Claims and Member Services at 617-253-5979
for a list of services provided at MIT Medical.
How do I know what services are covered under my benefit plan?
See your plan's Benefits at a Glance or Summary
Plan Description documents or call
Claims and Member Services at 617-253-5979.
To whom will I be referred?
Flexible Health Plan members will be referred to a Blue Choice participating
provider.
Traditional Health Plan members will be referred to an HMO Blue provider.
Will I be referred to a specific clinician?
Sometimes your MIT Medical clinician will refer you to a specific outside
clinician. At other times, they will refer you to a medical facility
or center, and the specific clinician will be determined when you make
the appointment. If you are referred to sleep centers, pain clinics,
surgical day centers, Boston IVF, or Reproductive Sciences, we need to
know the name of the specific clinician you will see. So, after making
your appointment at one of these facilities, contact your MIT Medical
clinician with the name of the outside clinician you will see.
What are my responsibilities in the referral process?
- Members of the Flexible MIT Health Plan
Kwajalein Option, and members
of the Flexible MIT Health Plan who want to use the flexible option
of their plan, do not need to obtain referrals for covered services.
Deductibles and co-insurance will apply.
- All other members of the Traditional and Flexible MIT
Health Plans must receive Health Plan approval for any outside visits before being
seen. Your MIT Medical clinician may make the appointment
for you or may suggest that you contact the outside clinician to schedule
an appointment. In either case, you must make sure you have received
Health Plan approval before going to the appointment or receiving any
services from the outside clinician.
- If you schedule the appointment yourself, you must contact
your MIT Medical clinician's office staff with the scheduled
date of the appointment and the outside clinician's name, address,
and phone number.
- For occupational therapy, physical therapy, and speech
therapy services, you must contact your MIT Medical clinician's
office staff to tell them the scheduled "first date of service" (the
date of your first therapy session).
- Ask the outside clinician to communicate periodic updates
on your health status to your MIT Medical clinician.
- Contact the MIT Medical referring clinician if the consulting
clinician refers you to another clinician. A new referral
request must be submitted and you must receive Health Plan approval before seeing
this new clinician.
How and when will I learn of the Health Plan's decision on my referral
request?
- You will receive a letter informing you of the decision
within seven business days. To find out the results
of the decision sooner, you may call Claims and Member Services at
617-253-5979 five business days after the referral request has been
submitted.
- Occasionally, a decision is deferred because the Health
Plans must wait to receive additional clinical information.
If this happens, a decision may take longer than five business days.
You will receive a letter within five business days to let you know
that the decision has been deferred.
Once approved, for how long is a referral valid?
Most referrals are valid for one year or until your insurance
expires (whichever comes first). Occupational therapy, physical therapy,
and speech therapy referral services must be completed within 60 days
of the first date of service.
How does the Health Plan decide whether or not to approve a referral
request?
Referral requests are reviewed by Health Plans Claims and Member Services
to determine if the requested service is a covered benefit
and if the service is available at MIT Medical. For members of the Traditional
MIT Health Plan, referrals for regularly covered services (this includes
most diagnostic tests) made to Blue Cross Blue Shield (BCBS)
HMO Blue providers are routinely approved within 2 business days. For members
of the Flexible MIT Health Plan or Flexible MIT Health Plan Kwajalein Option, referrals for regularly covered services
(this includes most diagnostic tests) made to Blue Cross Blue Shield (BCBS)
Blue Choice providers are routinely approved within 2 business days.
Requests for outside services that are available at MIT Medical, requests
for coverage of conditionally covered services, or requests
for benefit exceptions all require review by both the Health Plan's clinical
reviewer and the administrator of Claims and Member Services. The clinical/administrative
review will determine if the requested service is a "covered benefit" under
your health plan and will evaluate the medical necessity
of the service. Initial determinations on these requests are completed
within five business days.
What does conditionally covered mean?
All services are subject to BCBSMA's medical policy guidelines. "Conditionally
covered" refers
to certain services or medications that may be covered only
if a member meets specific medical criteria. Sleep studies
are an example of a conditionally covered service. Gastric
bypass is another example of a conditionally covered service.
What is an initial determination?
An "initial determination review" is the process the Health
Plan uses to initially review requests for benefit exceptions or coverage
for conditionally covered services. An initial determination
review may result in a request being approved or denied.
What if a referral request is denied?
If an initial determination review results in denial of the referral
or benefit exception, you have the right to appeal the decision. The
letter you receive about the initial determination denial includes the
justification, or reason, for the denial. The letter will also include
information on your right to appeal the decision and the process for
starting the appeal.
If you any have questions about referrals, coverage, or benefits,
please contact Claims & Member Services at 617-253-5979.
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