Managed Care

Managed care is an approach to healthcare intended to streamline services and provide healthcare that is quality and cost effective. Additionally, some managed care plans seek to assist members in staying healthy through prevention.

Managed care plans typically cover some or all of the costs of obtaining healthcare services. Members of such plans are usually required to seek services from within a network of approved providers. Some managed care plans allow members to obtain services from providers outside the network. However, such plans usually cover less of the bill when a participating provider is not used.

Referrals -The Benefit Inquiry Process

Unless it is an emergency, contact with your family doctor’s office is required prior to a referral request. This is most often accomplished by scheduling an office visit with one of our practitioners. When the doctor suggests that a referral to a specialist is necessary, a benefit inquiry will be submitted to your insurance company for approval. The referral, or HMO authorization, is generated by your insurance provider, not by your doctor. Once it is approved, the referral is mailed to your home. It is not advised to schedule an initial appointment to a specialist, a follow-up appointment, or arrange for any services outside of our office until you have obtained an authorized referral from your insurance company. It is your responsibility to make sure there is a referral or authorization in place prior to obtaining services outside of our office. At the specialist’s office, please present your referral form at time of service. Payment of services may be denied if you proceed without this authorization, and you could be responsible for the expense.

When you are covered by a managed care plan, you are required to choose a primary care physician (PCP). You must be assigned to one of our physicians before we can schedule you an appointment at our office.

ALL services you and your family receives, (except in the case of a life threatening emergency), must be provided by your Primary Care Physician or approved in advance by your insurance company. There is no retroactive approval. The insurance company does not grant us the power to authorize any out-of-network expense in any circumstance. You must use your best judgment and seek medical treatment if needed. Then you must appeal directly to your HMO for payment of those services. You will be responsible for the bill if you do not follow these rules.

If you receive a bill for services from a specialist office for which you have an valid referral/authorization, please contact your insurance company for an explanation of benefits (EOB) as to why the claim is not being paid.

The following information is intended to make your experience with managed care easier and less costly for you individually.

  • Your doctor’s office does not issue you a referral.  Our role is to submit a request for a referral to your insurance company.  You cannot see a specialist without a referral from your insurance company.
  • X-rays, ultrasounds, CT scans, and MRI’s must be obtained at a participating location, and a referral may be required.  If these tests are obtained without the proper referral, you will be billed at a much higher rate.
  • There is NO SUCH THING as a retroactive referral. All services must be authorized before you get them, or you will be responsible for the charges for the service.
  • You should try not to go to any ER except Delnor, Provena Mercy, or Rush-Copley unless you are transported to one by an ambulance. Your doctor cannot authorize an ER visit, even if you call.
  • If you happen to be out of town and are in need of medical care,  you must use your best judgment and/or contact your insurance company directly to find out about away from home care options.
  • Referral requests are submitted from our office every day, and we do our best to have them approved for you as quickly as possible. Please contact our office if you have not received your referral within a week of your appointment here and within a week prior to a scheduled appointment at a specialist’s office.
  • If a specialist requests a follow up appointment or orders any tests, including imaging and labs, you must obtain new referrals before obtaining these services. Labwork must be performed at in-network facilities.
  • Please contact our Managed Care Coordinator with any questions regarding the HMO referral process.