What is a referral?
A referral is defined as: The recommendation of a medical or paramedical professional. If you get a referral to ophthalmology, for example, you are being sent to the eye doctor. In HMOs and other managed care schemes, a referral is usually necessary to see any practitioner or specialist other than your primary care physician (PCP), if you want the service to be covered. The referral is obtained from your PCP, who may require a telephone or office consultation first.
The term "referral" can refer both to the act of sending you to another doctor or therapist, and to the actual paper authorizing your visit.
When is a referral made?
A referral request is processed when a provider determines that a patient needs medical services that are not available at MHC Healthcare, or when it is determined that a patient needs more specific care. MHC makes every effort to locate a specialist covered by your health plan or who offers payment plans or their own version of Sliding Fee Scale. If you have a preference of a particular specialist or clinician, please let your MHC provider know during your appointment, to ensure it is on the original request.
What are my responsibilities in the referral process?
- An appointment with an MHC provider is required for an assessment before they are able to determine if and to whom to refer you to. Upon receiving the referral in the mail (requests are available to be picked up at the MHC clinic as well) we suggest that you contact the outside clinician to schedule an appointment. In either case, you must make sure you have received approval from the MHC Referral Department before going to the appointment or receiving any services from the outside clinician.
- Ask the outside clinician to give your MHC provider periodic updates on your health status.
- Contact your MHC referring provider if the consulting clinician refers you to another clinician. In that case, a new referral request may need to be submitted, with approval from the insurance carrier before seeing a new clinician. This will be of importance should the clinician/physician request lab work. Our laboratory is only able to complete orders written by our providers, or by clinicians/physicians referred to by our providers. It will be necessary to have documentation in your medical chart supporting the referral.
- If your referral includes a predetermined number of visits, please contact our office before the expiration date or last service rendered, to prevent a delay in services. This may require an appointment. Our Referral Specialists will be able to assist you with the request and provide any necessary information.
How and when will I learn if my referral request has been approved?
You will receive your referral in the mail within seven to ten business days of the request being submitted. Occasionally, a decision is deferred because the Referral Department must wait to receive additional clinical information or are waiting for Prior Authorization from the health plan. If this happens, a decision may take longer than the expected ten business days.
What does Prior Authorization mean?
Prior authorization is a requirement that your physician obtain approval from your health plan to refer to a specialist or prescribe a specific medication for you. Without this prior approval, your health plan may not provide coverage, or pay for, the visit or medication.
Once approved, for how long is a referral valid?
Most referrals are valid for one year or until your insurance expires (whichever comes first).
How can I get a copy of an already approved referral?
Contact your provider’s office, and the Referral Specialist will be able to supply you with the copy.