Many health insurance plans, especially managed plans like HMO’s, require you to receive approval from your pediatrician (PCP) before you take your child to a specialist and then you must obtain a referral number.
Please be aware that insurance companies can deny payment for services even if you have a referral. You must call your insurance company directly about what services may not be covered.
If your insurance is the “managed” type (if you don’t know, call your insurance company), please follow these steps:
Step 1: Verify with your company that you need a referral. Even if your insurance is managed, you may not need a referral for some services. Example: most companies do not require a referral for annual or biannual eye exams, or for laboratory tests. Most companies have PPO plans that do not require referrals. Check with your company before you begin the referral process.
Step 2: Speak with your pediatrician or nurse practitioner about the need for a referral and receive medical approval for that referral.
Step 3: Make an appointment with the specialist whom your provider has referred you to. When you call the specialist, be sure to ask for the specialist’s provider ID number for the type of insurance that you have and the specialist’s NPI number. At that time, please confirm that the specialist is a member of your health insurance network; otherwise you may be subject to “out of network” costs.
Step 4: Inform our referral coordinator of the information necessary to process your referral paperwork. You can do that in these ways:
- Click here to fill out our online Referral Request Form. Furnish the information requested and click on submit.
- Pick up our Referral Request Form in our office and fill it out when you come to the office or you can mail or fax it back to us.
- Click here to download a printable (PDF) copy of the Referral Request Form that you can print, fill out, and mail or fax to us.
- Call the Centre Pediatrics referral line at (617) 735-8585, Option 4. Leave us your full name, your child’s name, your address, and your fax number if you have one. We will mail or fax to you our Referral Request Form which you complete and mail or fax back to us.
Step 5: You may also request a referral via Patient Gateway.
It takes approximately 5 business days to process your referral. Most referrals are now electronic, so there is no hard copy. Your specialist should be able to access your referral information via the POS devise or over the telephone. If you have questions, please contact our Referral Coordinator at (617) 735-8585.
The Truth about Referrals
Myth: Your Centre Pediatrics Primary Care Physician (PCP) or nurse practitioner notifies the Centre Pediatrics referral coordinator or your insurance company of your need to take your child to a specialist.
Fact: No, the providers do not typically notify the referral coordinator or your insurance company. We rely on you to provide the information about your referral since frequently the specialist whom you will see or the time of the appointment changes. Please fill out our referral request form so that we have all of the information that we need to process your referral. You can submit this form to us over our web site or you can call our referral line (617) 735-8585, Option 4, to leave us your fax number or address so that we can fax or mail the form to you. You can also pick up the form in our office.
Myth: Your Centre Pediatrics PCP or nurse practitioner knows which specialists take your insurance.
Fact: With so many insurance companies, it is impossible for your Centre Pediatrics PCP or nurse practitioner to know which specialists are approved by your company. Make sure that you ask the specialist’s office if that specialist takes your insurance when you set up your appointment. If the specialist does not take your insurance, you may be subject to “out of network” costs.
Myth: If you haven’t received a copy, your referral hasn’t been processed.
Fact: Most referrals are now electronic via a machine called a POS device or via the telephone. Therefore, there are no hard copies. Your specialist should be able to access the information via the POS device or the telephone. Some referrals are done verbally and you or your specialist will be called with the referral number.
Myth: Your referral was processed so you won’t be getting bills from the specialist’s office.
Fact: Our office can process a referral, but an insurance company can still deny coverage. Each company has different benefits and different plans within that company. What a company covers under your plan is based on your individual or group policy. It is your responsibility to know what coverage your insurance company allows. You may also be responsible for co-payments or deductibles. Call your insurance company to be sure.
Myth: The specialist’s office knows you will need a referral and will obtain one for you.
Fact: Again, with so many different insurance companies and plans, it is difficult to know for certain who needs a referral and who does not. In general, if you have an HMO, you will need a referral. On occasion, the specialist’s office will call Centre Pediatrics for a referral, but do not depend on it. You are ultimately responsible and will have to pay for specialist’s charges if you do not obtain a referral.
Managed Care Reform, a law that became effective on January 1, 2001, has changed the referral system in two significant ways.
- You no longer need a referral for emergency room services.
- You no longer need a referral for ob/gyn services.