Understanding Referrals
Primary care providers (PCPs) are your first line of defense when it comes to health care. Your PCP plays a big role in your health by doing checkups to spot potential problems, recommending screenings or vaccinations you may need, and sharing health and wellness education.
Plus, when you’re sick or have another health concern, your PCP is usually the first person you see. And if you have a chronic condition like high blood pressure, your PCP will work with you to keep it under control. Your PCP also can manage your medications, making sure you take your drugs correctly and adjusting prescriptions as needed.
Clearly, PCPs can and do handle a lot! However, there may be times when they decide that a particular health issue should get more focused care. In these types of situations, they will usually refer you to a specialist.
A referral is basically a request from your PCP to a specialist asking that they accept you as a new patient to evaluate, diagnose, and/or treat a condition or issue. Specialists are health care providers whose practice focuses on very specific fields of medicine (skin, heart, brain, digestive system, etc.). For example, if you have a skin condition, your PCP may refer you to a skin doctor (dermatologist). Or, for possible heart problems, you may be referred to a heart expert (cardiologist).
Referrals are almost always required for HMO (health maintenance organization) or POS (point of service) health plans. With PPO (preferred provider organization) health plans, you don’t need referrals. However, you should make sure any specialists you see are in-network to avoid high out-of-pocket costs.
Below, we explain the referral process so you understand what to expect and who to reach out to if you have questions.
What Happens When Your Provider Orders a Referral?
When a provider decides a patient needs a referral to a specialist, they will create a referral request. This immediately gets sent to Innovista Medical Center’s internal referral coordinator. Each location has a dedicated referral coordinator.
Unless you know a specialist that you would like to see, or your PCP has a specific provider in mind, the referral coordinator will find a specialist close to your home zip code.
The coordinator enters the referral information into an online portal. This will help verify that the specialist is in-network with your insurance and accepting new patients. The coordinator then requests an approval from the insurance company.
Once approved, the coordinator sends the referral forms to the specialist. This includes your medical records and the reason for the referral. You will be notified via your MyChart patient portal that the referral has been sent to the specialist. Shortly after, someone from the specialist’s office will reach out to schedule an appointment. Be aware that there may be a window of time in which you can use the referral. It could be as little as one month, so be sure to make that appointment as soon as you are able to.
The specialist should send a report to your PCP with details of the visit, including diagnosis, treatment, and recommendations for follow-up. This communication is important. It keeps your PCP up to date on your health and allows them to continue your care.
How Long Does the Referral Process Usually Take?
There are two different kinds of referrals: Routine and urgent.
Routine referrals usually take about a week (five business days) to complete.
Urgent referrals are for matters the PCP feels need quicker follow-up, so they usually are approved within 72 business hours.
What Happens If a Referral Request Is Denied?
In-network specialists are usually approved. If a referral request is for an out-of-network specialist, the request goes under review with the insurance company. It usually takes at least five business days once it’s submitted for a response to be given.
Unfortunately, most out-of-network referral requests are denied, especially if there are in-network specialists near you who are accepting patients. But if an out-of-network request does get approved, it’s usually for a shortened amount of time and visits.
We have a system in place that allows us to see if a specialist is in or out of network before we submit a request to the insurance. If the referral coordinator believes a specialist will be denied, they will give you options for specialists within your network.
Can Patients Pick Their Own Specialist?
Patients always have a say in who they would like to see. If you have a specialist in mind, share their name with the referral coordinator, who will verify that the provider is in-network before moving forward with the rest of the coordination process.
Can a Referral Request Come from a Patient Instead of a Provider?
If you want to get a referral on your own, reach out to your specific clinic location and speak to the front desk staff. They will need to know:
- What the referral is for
- If you are a new or established patient
- If you have seen a specialist previously, and
- If the concern is something you personally want evaluated
Depending on the request, an Innovista Medical Center provider will decide if you need to come in for an in-person visit to create the referral and start the approval process.
Questions?
If you have any questions about referrals or referral status, reach out to Innovista Medical Center’s referral department, which is led by Lead Referral Coordinator Tommy Flores. You can also ask to speak to the referral coordinator who works in your specific clinic.
If you have questions about your insurance benefits or which specialists are in-network, reach out directly to your insurer. Keep in mind, since Innovista Medical Center provides care exclusively to Blue Cross and Blue Shield of Texas members, all clinics have representatives from the insurance company working in-house to answer your insurance questions. You can call or come to the clinic to talk to them in person.
As always, we are here to help you navigate all your health needs, including referrals. Don’t hesitate to reach out. We are happy to help!
