A referral is a formal request from an MIT provider asking the MIT Health Plans Office to approve services 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.
Your provider will tell you that he or she is submitting a referral request for you to receive services outside of MIT Medical. Your clinician may refer you to a specific outside clinician or facility, or you may need to work with MIT Medical’s Referral Office to identify an appropriate in-network provider and make your first appointment. You can call or stop by the Referral Office on the third floor of MIT Medical, or they will give you a call to set things up.
The referral process is not complete until the MIT Health Plans Office approves the clinician’s referral request. Most patients receive a letter with our decision within seven to 10 business days. If you don’t receive this letter before your first scheduled appointment with an outside provider, you can call Claims and Member Services at 617-253-5979 to confirm that the referral has gone through.
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.
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.
- 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.
You will receive a letter informing you of the decision. In most cases, the letter will arrive within seven to 10 business days. If you don’t receive this letter before your first scheduled appointment with an outside provider, you can call Claims and Member Services at 617-253-5979 to confirm that the referral has gone through.
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.
In the case of diagnostic tests, such as MRIs or colonoscopies, MIT Medical’s Referral Office will schedule your appointment for you at a convenient time. For other types of outside services, the Referral Office is available to help you identify in-network providers and make appointments. Or you can schedule those appointments yourself, and then contact the Referral Office to let them know the provider’s name and the date of your first appointment.
Remember, if you don’t receive a letter about your referral from the MIT Health Plans Office before your first scheduled appointment with an outside provider, you can call Claims and Member Services at 617-253-5979 to confirm that the referral has been approved.
Contact the MIT Medical clinician who made the initial referral. He or she 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.
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.
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 Office 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.
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.
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 a Doctor” webpage
2) Choose either the “Healthcare Provider” or “Medical Facility” tabs on the left side of the form
3) Use the tabs on the top of the form to search by “Name” (of provider or facility) or “Specialty”
4) Fill in the required fields; in the pull-down menu for “Network,” select “Blue Cross PPO/EPO”
5) Click on the “Search” button
- When you see an in-network provider, you’ll be charged a $20 copay for most office visits, $50 for emergency room visits and most diagnostic tests, and $100 for hospital admissions. To determine copay amounts for specific services, see the current MIT Student Health Plan Overview.
- When you see an out-of-network provider, you’ll have a 20 percent coinsurance charge, which means you’ll be responsible for paying either 20 percent of the provider’s actual charge or 20 percent of the amount approved by Blue Cross Blue Shield of Massachusetts (BCBSMA) as payment to the provider for this service. An out-of-network provider may also choose to bill you for the difference between his or her usual fee and the Blue Cross allowed amount—a practice referred to as “balance billing.” This balance-billed amount is in addition to the 20 percent coinsurance and does not count toward Blue Cross’s calculation of your annual out-of-pocket costs.