Referral Request Process: Frequently Asked Questions
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 page on mental health benefits. 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?
- When is a referral made?
- How do I know what services are available at MIT Medical?
- How do I know what services are covered under my benefit plan?
- To whom will I be referred?
- Will I be referred to a specific clinician?
- What are my responsibilities in the referral process?
- How and when will I learn of the Health Plan's decision on my referral request?
- Once approved, for how long is a referral valid?
- How does the Health Plan decide whether or not to approve a referral request ?
- What does conditionally covered mean?
- What is an initial determination?
- What if a referral request is denied?
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 in our directory. 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 brochure or Summary Plan Description documents under "Resources" on the MIT Traditional Health Plan or MIT Flexible Health Plan pages, or call Claims and Member Services at 617-253-5979.
To whom will I be referred?
- Traditional Health Plan members will be referred to an HMO Blue of Massachusetts provider.
- Flexible Health Plan members will be referred to a Blue Choice participating 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 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 7-10 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, 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 further questions about referrals, coverage, or benefits, please contact Claims & Member Services at 617-253-5979.
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