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