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FAQ: Referrals

What is a referral?

A referral is a formal request from an MIT provider asking the MIT Health Plans Office to approve services outside of MIT Medical.

Do I need a referral to get care outside of MIT Medical?

  • MIT Student and Affiliate Extended Insurance Plans: No. With the MIT Student or Affiliate Extended Insurance Plans, you may choose to see a provider outside MIT Medical without a referral. Both of these plans are Blue Cross Blue Shield “preferred provider organizations” or “PPOs.” This means that when you see a provider who participates in the Blue Cross Elect PPO network—with or without a referral—the insurance plan will cover more of the cost, which means you will pay less. But even though you don’t need a referral, there are some good reasons to get one.
  • MIT Traditional Health Plan: Yes. Members of the MIT Traditional Health Plan need referrals if they want their insurance to cover care outside of MIT Medical. When you have a referral to an outside specialist or other outpatient facility, you’ll have only a $10 copay for your visits, and you can fill your prescriptions from the outside provider at the MIT Pharmacy.
  • MIT Choice Plan: No. But with the MIT Choice Plan, getting a referral means you’ll have only a $10 copay for your visits and can fill prescriptions from the outside provider at the MIT Pharmacy. However, the Choice Plan also has an “out-of-network” benefit, which means you can choose to see an outside provider without a referral and still be covered for a portion of the cost. For example, when you use your out-of-network benefit with a Blue Cross Blue Shield-participating provider, you’ll have a 25 percent coinsurance charge (25% of the amount approved by Blue Cross as payment for this service) once you have paid your calendar-year deductible ($500 per member or $1,000 per family). And once the money you’ve paid for that year’s deductible plus coinsurance equals $2,500 per family or $5,000 per member, your out-of-network benefits will be covered in full, minus any required copays.
  • MIT High Deductible Health Plan: No. With the MIT High Deductible Health Plan, you may choose to see a provider outside MIT Medical without a referral. This plan is a Blue Cross Blue Shield “preferred provider organization” or “PPO” plan. This means that when you see a provider who participates in the Blue Cross Elect PPO network—with or without a referral—the insurance plan will cover more of the cost (once you’ve met your deductible), which means you will pay less.

How does the referral process work?

Outside services we regularly cover, including most diagnostic tests with in-network providers, are usually approved within two business days. Other types of referral requests require a longer review process.

But as long as your clinician clearly documents your need for a service that is not readily available at MIT Medical, the referral is likely to be approved quickly. If the Health Plans Office needs to ask your clinician for additional information, the referral request can take a bit longer. In that case, we will contact you to let you know that the decision has been deferred.

How does the MIT Health Plans Office decide whether or not to approve a referral request?

The Health Plans Office needs to make sure the requested service is a benefit that is covered by your insurance plan and that the service isn’t available at MIT Medical. There are many outside services we routinely cover, including most diagnostic tests with in-network providers.

How long will it take for the MIT Health Plans Office to make a decision on my referral request?

So long as your clinician clearly documents your need for a service that is not readily available at MIT Medical, the referral is likely to be approved quickly. Outside services we regularly cover, including most diagnostic tests with in-network providers, are usually approved within two business days. Typically, you will receive a letter with our decision within seven to 10 business days.

If we have to ask your clinician for additional information, the referral request can take a bit longer. In that case, you will receive a letter within five business days to let you know that the decision has been deferred. And some types of referral requests always require a longer review process.

What types of referral requests require a longer review process?

The following types of referral requests always require a longer review process:

  • A request for outside services that are already available at MIT Medical
  • A request for services, such as sleep studies or gastric bypass surgery, that are covered only for patients who meet specific medical criteria
  • A request for a “benefit exception”—a drug, treatment, or diagnostic test that is not normally covered by your insurance.

How will I find out if the MIT Health Plans Office has approved my referral request?

A referral specialist at MIT Medical will contact you by phone or through the HealthELife portal to help schedule the outside appointment. Once your appointment is confirmed, you can assume that the referral is approved and any necessary health insurance authorizations are completed.

What if a referral request is denied?

If the MIT Health Plans Office denies a referral request or benefit-exception request, you have the right to appeal the decision. You will receive a letter that includes the reason for the denial and information on how you can appeal.

I have a referral to get services outside of MIT Medical. How do I make the appointment?

We make it easy for you. A referral specialist at MIT Medical will contact you by phone or through the HealthELife portal to find out when you’re available to go to the outside appointment and then will schedule the appointment for you. We’ll let you know when your appointment has been confirmed and your referral is approved.

Can I make my own appointment?

Yes, you can make your own specialist appointment if you prefer. After making the appointment, call the MIT Medical referral office with the following information:

  • Name of your primary care provider (PCP) at MIT Medical,
  • Specialist’s first and last name and NPI (their unique 10-digit identification number),
  • Reason for seeing specialist, and
  • Date of your upcoming appointment.

Remember, if you see a specialist without approval from Blue Cross Blue Shield of Massachusetts or do not let us know the date of your appointment, you may have to pay the cost yourself.

I saw a specialist outside MIT Medical with an approved referral. That specialist wants to refer me to a different specialist. What should I do now?

Contact the MIT Medical clinician who made the initial referral. They will have to submit a new referral request for you to see a different specialist, and the MIT Health Plans Office must approve the new referral request.

For how long is an approved referral valid?

Most referrals are valid for one year from the date of the approval or until your insurance expires—whichever comes first. But referrals for occupational therapy, physical therapy, and speech therapy always expire at the end of the current calendar year. To continue these covered services in a new year, you must get a new referral that takes effect on or after January 1.

If my insurance plan doesn’t require a referral to get care from an outside provider, why should I bother to get one?

Even if your health plan doesn’t require a referral, there are a few good reasons to get one:

  • Save time: Using MIT Medical’s referral specialists allows you to avoid the hassle of finding an appropriate, in-network provider and booking the initial appointment.
  • Coordinate care: With a referral, your MIT Medical provider automatically gets reports from the outside clinician or facility and can follow up to make sure you’re getting everything you need.
  • Fill prescriptions on campus: With a referral on file, you can fill prescriptions from the outside provider at the MIT Pharmacy with a significantly lower copay than you would have at a retail pharmacy.

What’s the difference between an “in-network provider” and an “out-of-network provider”?

An “in-network provider” is a clinician or facility participating in the Extended Plan’s “preferred provider organization” (PPO) network managed by Blue Cross Blue Shield of Massachusetts (BCBSMA)—the Blue Cross Elect PPO. An “out-of-network provider” is a non-participating clinician or facility. When you see a provider who participates in the PPO network, the insurance plan will cover more of the cost, which means you will pay less.

How can I be sure that I’m using an in-network provider?

You can use the Blue Cross Blue Shield of Massachusetts (BCBSMA) website to find a participating doctor or facility or to find out if a specific clinician or facility is part of the network:

1)     Go to the BCBSMA “Find Medical Care” webpage.

2)    Select appropriate provider group: Specialist, Behavior Health, or Vision.

3)    Select appropriate subspecialty.

4)    Select filter criteria from the top, drop-down menu item on the right.

5)    Refine your results as needed.

6)    List will update automatically.

How much will I have to pay to see a provider outside MIT Medical?

Refer to your insurance plan information for details. Different plans have different copays or coinsurance rates for in-network and out-of-network providers.