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Referral Request Process
Frequently Asked Questions for Students and Affiliates with the Extended Insurance Plan (SEIP or AEIP)
This document contains information about referrals for outpatient medical or surgical services only. 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 Student Health Plan Overview or
Summary Plan Description, or call Claims
and Member Services at 617-253-5979.
To whom will I be referred?
All referrals are made to a Blue Cross Blue Shield (BCBS) PPO 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?
- You 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. Referrals for regularly covered
services (this includes most diagnostic tests) made to Blue Cross Blue
Shield (BCBS) PPO 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?
"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 a benefit exception?
A "benefit exception" is a request to the MIT Health Plan to approve
services that are not covered under your benefit plan or to approve services
outside of MIT Medical that the Health Plan has determined are available
at MIT Medical. Requests to approve outside office visits in conjunction
with certain types of tests or procedures are considered "benefit exception" requests.
A request for a non-covered service, such as for treatment
of excessive facial hair is also considered a benefit exception request.
Your clinician will make a benefit exception request to the Health Plan
when he or she determines that such services are medically necessary
and appropriate.
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.
What is my financial responsibility if I am referred
for services outside of MIT Medical (including physical
therapy at the Z Center)?
- For occupational therapy, physical therapy, and speech
therapy, $25 deductibles and co-insurance will apply . Co-insurance
rates will be 20 percent for visits 1-16, and 50 percent for visits 17-24.
- For office visits, 20 percent co-insurance will apply.
Co-insurance does not apply to out-of-pocket maximum.*
- For diagnostic studies (e.g., CT scans, MRIs), 10 percent
co-insurance will apply.
What is a deductible?
A "deductible" is a fixed dollar amount that you must pay before benefits
are provided for certain covered services.
What is co-insurance?
"Co-insurance" is the amount that you must pay for certain covered
services and is based on a percentage of either the provider's
actual charge or provider's allowed charge.
What is a co-payment?
A "co-payment" is a fixed dollar amount you must pay for certain covered
services.
If you any have questions about referrals, coverage, or benefits,
please contact Claims & Member Services at 617-253-5979.
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