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Referrals for patients enrolled in the Student Extended Insurance Plan

What is a referral?

A referral is a request from a clinician to the MIT Health Plans Office 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.

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When is a referral made?

A clinician makes a referral request when he or she determines that a patient needs medical services that aren’t available at MIT Medical.

The Extended Insurance Plan is a preferred provider organization (PPO) and does not require referrals for coverage of outside medical services. However, MIT Medical’s pharmacy license allows us to fill only prescriptions written by our clinicians, or by clinicians to whom they have made referrals. If you see an outside clinician without a referral, any prescriptions written by the outside clinician needs to be filled at a participating Express Scripts pharmacy and will have a higher copay. For more information, see the MIT Student Health Plan Overview.

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How do I know what services are available at MIT Medical?

Services at MIT Medical are listed in our online directory. You may also call Claims and Member Services at 617-253-5979 to request a list of services provided at MIT Medical.

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How do I know what services are covered under my benefit plan?

See the Student Medical Plan – Benefit Description (2010-11) or the MIT Affiliate Health Plan 2010-11 Overview, or call Claims and Member Services at 617-253-5979.

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To whom will I be referred?

All referrals are made to a Blue Cross Blue Shield (BCBS) PPO provider.

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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.

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What are my responsibilities in the referral process?

  • Patients who have the Extended Insurance Plan do not need a referral from an MIT Medical clinician for services outside MIT Medical. However, if you schedule an appointment with an outside clinician without a referral 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. This is necessary if you want to have prescriptions filled at the MIT Medical pharmacy.
  • It is your responsibility to know your benefits, including visit limits. For more information, see the MIT Student Health Plan Overview. If you have any questions, please contact Claims and Member Services at 617-253-5979.
  • You should ask the outside clinician to contact your MIT Medical clinician with periodic updates.

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How and when will I learn of the MIT Health Plans office'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 MIT Health Plans Office 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.

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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 are a calendar year benefit, so you must get a new referral on January 1.

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

Referral requests are reviewed by 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 PPO providers are routinely approved within two business days.

Requests to receive outside services that are available that are available at MIT Medical, requests for coverage of conditionally covered services, or requests for benefit exceptions all require review by both the clinical reviewer in the MIT Health Plans Office 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.

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What does “conditionally covered” mean?

All services are subject to Blue Cross Blue Shield of Massachusetts medical policy guidelines. “Conditionally covered” refers to certain services or medications (for example, sleep studies or gastric bypass) that may be covered only if a member meets specific medical criteria.

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What is an “initial determination”?

An “initial determination review” is the process the MIT Health Plans office uses to initially review requests for conditionally covered services or other unusual requests. An initial determination review may result in a request being approved or denied.

If you any further questions about referrals, coverage, or benefits, please contact Claims & Member Services at 617-253-5979.

Resources

Student Enrollment Questions

Health Plans Office
E23-308
617-253-4371
stuplan@med.mit.edu

Walk-in/Phone Hours
M–F, 8:30 a.m. to 5 p.m.

Coverage Questions

Claims and Member Services
E23-191
617-253-5979
mservices@med.mit.edu

Phone Hours
M–F, 8:30 a.m. to 5 p.m.

Walk-in Hours
M–F, 9 a.m. to 5 p.m.