Quick Guide To Patient Referrals At MeritCare
Thank you for choosing MeritCare for your healthcare! The following information will explain the process your doctor uses to send – or "refer" – you to another healthcare doctor, in case you should require care away from MeritCare. This information will also explain how MeritCare communicates these referrals to your insurance plan, if they require special authorization.
Understanding Your Health Plan
Before getting started, we encourage you to read your insurance handbook carefully, so you understand the benefits and limitations of your insurance plan. Some questions you should consider as you read include:
- Do I need to seek care from one doctor, clinic or group of doctors to receive my best benefits?
- If care is needed outside my primary care doctor's office, clinic or group, do I need authorization or insurance "referral"?
- Does my insurance plan cover preventative or screening tests?
- Am I also required to seek different types of care, such as chiropractic, mental health or chemical dependency services, from a specific group of doctors?
- Am I required to notify my insurance plan when I am admitted to the hospital?
Once you've read your insurance plan booklet, if you still have questions regarding your insurance benefits, contact your human resources representative or your insurance plan. The telephone number to call your insurance plan is printed on the back of your insurance card.
What is a referral?
People in the healthcare field use the word "referral" in two distinct ways. When a healthcare doctor uses the term, they mean they are recommending that you see a different type of doctor (i.e., a specialist). When your insurance plan uses it, they mean you need special authorization or approval before you can see that specialist or other doctor outside your chosen clinic, care system or doctor network. If you see a doctor without the necessary authorization, you will most likely be responsible for a significant portion of those healthcare costs.
My doctor recommends I see a different doctor. Isn't that good enough?
Every insurance plan is different. In some plans, if you seek care by a doctor other than your primary care doctor without following the process defined by your insurance plan, you may be accountable for those healthcare costs. It is your responsibility to understand your insurance benefits. Check with your insurance plan before your appointment to make sure the appropriate authorizations are in place.
MeritCare Referral and Insurance Authorization Processes
Healthcare decisions are critically important and should never be taken lightly. We firmly believe that the best healthcare decisions are those which involve both the patient and their primary care doctor, working together to coordinate care as it is required. To that end, we require that all referrals MUST be made by a primary care doctor before treatment is given. Referrals made after the fact (sometimes called "retrospective" referrals) WILL NOT be authorized or approved.
Why can't I just go to see whatever doctor I choose?
Actually, you can. It is your right as a patient to receive care from whatever doctor you want. However, if you elect to see a non-MeritCare doctor without getting a referral first, and your insurance plan has an authorization process you do not follow, you will most likely end up being responsible for a significant portion of the cost involved.
Your primary care doctor is your best resource for finding care that is appropriate to your needs and that falls within the guidelines established by your insurance plan. In many cases, MeritCare can provide the services you need internally. We are the largest group practice between Minneapolis and the West Coast, with 36 regional locations and specialists in 70 different fields of medicine. We pride ourselves in offering the most advanced care and can often save you time (eliminating the need to travel, etc.) and money over comparable, out-of-network options. Even when we can't provide the care you need internally, we can coordinate with your doctor to ensure you are receiving appropriate treatment while still maximizing your insurance benefit.
So how do I go about getting proper authorization for a "referral"?
Ideally, you should work with your primary doctor to determine the care you need
(a primary care doctor is the MeritCare doctor you've chosen for your everyday medical care). Primary Care Physicians are doctors with practicing specialties of Family Practice, General Practice, Internal Medicine, Pediatrics and OB/Gyn. If you don't have a primary doctor and are seeking a referral outside of MeritCare, you will be asked to see a MeritCare doctor to make sure the referral is necessary. If the doctor decides that specialty care is needed and not available at MeritCare, he or she will submit a request for referral to MeritCare's Referral and Managed Care Department. This group of associates has knowledge and expertise regarding the authorization requirements of many different insurance plans and will use this knowledge to make sure the correct process is followed.
How does my MeritCare doctor decide where to send me for specialty care?
If your primary care doctor determines you need specialty care, a diagnostic test or restorative care (physical, occupational or speech therapy), he or she will look at the following options and determine the appropriate course of action. Based on your needs and best interests, he/she may:
- Refer you to a MeritCare doctor who travels to your community
- Refer you to a different MeritCare location
- Refer you to a local, non-MeritCare doctor or facility that participates with your insurance plan
- Refer you to an out-of-area or out-of-state doctor
My insurance plan indicates that the "Medical Director of Managed Care" makes my referral decision. What does this mean?
If you signed up with MeritCare Clinic or the MeritCare network through your health plan, the Medical Director of Managed Care is a MeritCare doctor who makes the referral decisions. This doctor reviews your primary care doctor's recommendations for care (or your request) and works with them to make the best decision whether or not to authorize the referral.
How long does this process take?
Unless you need care within 24 hours, authorization decisions are communicated to your insurance plan after receiving the necessary information.
How is this communicated to me?
You will receive a letter from your insurance plan regarding the referral decision. If you can't wait for the letter, call your insurance plan.
I forgot to get authorization. Can't I call my doctor for a referral? I have in the past.
Effective 7/1/02, MeritCare will no longer review requests for referrals after the care has been provided. The only exceptions will be for:
- Care given in an emergency center
- Urgent care while traveling
- Cases where your doctor sent you for services and the insurance plan wasn't notified
- Urgent/Emergent Hospital Admissions
- Transfer from a Hospital to another level of care
What can I do if I disagree with the decision to deny my referral?
If your referral authorization is denied, you have the right to appeal. Contact your health plan regarding the appeal process.
Patient Rights and Responsibilities
- Patients have the right to receive care from any doctor they choose. However, by electing this choice, the patient may be "self-referring" and may be responsible for a greater portion of the cost.
- Patients have the right to appeal referral denials and should be encouraged to contact their health plan regarding the appeal process.
- Patients have the responsibility to understand their benefits. Referrals are never a guarantee of benefits. Patients should be encouraged to verify these benefits with their insurance plan before going to a doctor outside the MeritCare network.
What if I have other questions about my insurance?
We encourage you to read your insurance handbook and contact your insurance plan with questions about your health insurance benefits. Their number is located on the back of your insurance card.
If you have specific questions about MeritCare's referral processes, feel free to give our Referral and Managed Care Services a call at 701-234-2631 or 1-800-437-4010 and ask for extension 2631.