Many insurance plans, especially “capitated” plans such as Keystone Health Plan East, have complicated rules regarding specialist visits and referrals. Even within the same insurance company, policies and procedures may vary from one employer to the next. As a result, it is impossible for Kressly Pediatrics to know the details of every patient’s insurance plan.
When you need to visit another doctor or facility, it is your responsibility to know your specific benefits. If you are unsure, you can get more information by calling the member services number on the back of your insurance card. We recommend that you know the answers to the following common questions before you need them:
- Where should I get bloodwork and other labwork done?
- Where should I get xrays and other imaging studies done?
- Do I need a referral to see a specialist?
- What do I do if the specialist wants me to have additional labwork or xrays or therapy?
- If I choose to see a specialist who is “out of network,” how much of the bill will I be responsible for?
If your insurance plan does need referrals, our office policy requires a minimum of two (2) business days to process a routine referral. You can request one online by logging into Online Patient Services. We recommend that you do this as soon as you make an appointment with a specialist.
We cannot “back date” a referral. If you are seen by a specialist without a referral, we will not be able to process one after the fact. If you call us on the way to the specialist, we may not be able to process your request in time for your scheduled visit. You may be asked to reschedule the appointment if the specialist cannot verify that you have a referral in the system. If you need to see a specialist for a follow-up appointment, inquire if you will need an additional referral or if the original referral included a certain number of follow-up visits within a defined period of time.
If you would like an “out of cap” referral (to visit a specialist or facility that is out-of-network), we require 5 business days to handle such requests. This process often requires additional documentation and multiple contacts with your insurance company. Before contacting us, we ask that you call your insurance company to confirm whether your policy covers such services, and if so, to get the details on what information we will need to process the request.
If your child needs a referral for therapies including physical therapy, occupational therapy or speech therapy, it is likely that there will be limits to how many visits your plan will cover and specific locations that you must use for care.
Please remember the above information is for your benefit so that your insurance company will pay for services. If you do not comply with the rules that are outlined by your specific insurance policy, you may be responsible for all or a portion of your bill.