Health and Wellness
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A key to the success of Coordinated Health/Care™ is receiving notices of healthcare services that you are seeking. Through such notice, the physicians can better help you through healthcare services, maximize your benefits under your employer's plan, and assure that the physician is aware of all healthcare events.

Am I required to get a PCP referral before seeing a specialist?
The Coordinated Health/Care program strongly encourages you to follow this approach, and you receive an enhanced benefit when you do so. However, you may also visit specialists without a referral and receive the standard benefit.

What are the benefits of getting a referral before seeing a specialist?
You have lower co-pay for office visits with specialists to whom you have received a PCP referral. If you choose to visit specialists on your own without such a referral, you pay your normal co-insurance. In addition to helping you avoid visits to the wrong specialist, a referral from a Family Doctor is also communicated to the Care Coordinators. If you are being referred to an out-of-network physician (which is surprisingly common) or the service you seek has a limited benefit, the Care Coordinators will call you and notify you in advance -before you incur an out-of-pocket expense.

What is pre-certification?
Your health plan requires that certain medical services be verified for medical necessity. This verification process is called “pre-certification” and the services needing this are listed on your ID card. Your physician should provide Coordinated Health/Care with the needed information. Once this has been received, both you and your physician will receive a “determination” letter on the requested service. If you haven't received a letter from Coordinated Health/Care prior to an elective procedure, please call a Care Coordinator.

How do referrals and pre-certifications help the healthcare process?
Your physicians use the referral and pre-certification process as a means of coordinating your care. These notifications enable the physicians to transfer information on a patient, keep care in-network to maximize your benefits, and make sure you get the full range of services without leaving you to find your own services. In addition, referrals may ensure that you will be seen faster by a specialist. In fact, many specialists will not see new patients without a referral from a Family Doctor. These notifications also serve to ensure in advance that treatment is a covered service under the Plan so there are no surprises for the patient (i.e., learning after the fact that a procedure is cosmetic or experimental and is therefore not covered by the Plan).