When your primary care provider (PCP) determines you need specialized care, your PCP will “refer” you to a specialized provider. A referral may be required by your insurance before your plan will provide payment for certain services. Below are answers to commonly asked questions about referrals.
How do I know if my health plan requires referrals?
Check your insurance plan member portal for coverage guidelines or call your plan’s member services department at the number on your card. It is important that you fully understand your plan’s referral requirements. If you do not get a required referral prior to receiving non-emergency care, you may be responsible for the entire bill (not just a co-payment or deductible).
Why do I have to check with my PCP before seeing a specialist?
Depending on your insurance plan, it may be required. Your PCP best knows your medical history and is most qualified to work with you in deciding if you need to see a specialist.
Do I need a referral for an X-ray?
It depends on what you are having done. If it is a routine X-ray, your PCP can send the order and you can have it done the same day. If you are having a “Hi-Tech” exam, such as an MRI, CAT scan, or PET scan, your insurance company may require prior approval before the test can be performed. Once an Outer Cape Health Services Referral Coordinator receives an authorization or denial, you will be contacted about scheduling the appointment. For all other testing, such as ultrasounds, mammograms, and bone densities, Cape Cod Hospital will call you directly to schedule. If you do not hear from Cape Cod Hospital within 3 days, we suggest that you call the Hospital’s central scheduling at (508) 957-8600.
If your referral is other than Cape Cod Hospital, you will be asked to call directly to register and schedule your appointment.
How soon will I hear from an Outer Cape Health Services’ Referral Coordinator?
You will hear from the Referral Coordinator within 10 business days of our receiving the request for referral from your provider. A Referral Coordinator will contact you via our Patient Portal or by phone, at which time you will be given the specialist name and phone number to contact the specialist directly.
If you have not registered on the Patient Portal, please call our Patient Access Center at (508) 905-2888. We will be happy to help you through the process.
If you have already signed up for the Patient Portal, that is the default method in which we will notify you of your referral status unless your referral is marked urgent by the provider. In that case, you will receive a phone call.
How soon will I get my appointment with the Specialist?
Most specialists will call you directly to schedule the appointment. If the specialist is unsuccessful in reaching you, they will notify the referral department who will then inform your provider.
Specialists do their best to get you an appointment in a timely manner depending on what you are being seen for; however, some specialists are very busy. If you do not hear from them in a timely manner, you can call the specialist office directly.
What if I see the specialist without obtaining a referral?
Specialists should be aware if they should have a referral prior to seeing you. If you see a specialist and a referral is required, your PCP may not give the referral after you have seen the specialist. If you receive a bill from the specialist and you did not get a referral, you will need to discuss this with your insurance company. Ultimately, you are responsible to obtain a referral prior to your appointment. Please allow up to 10 business days for this to be completed.
How long should I wait before I hear from someone at Outer Cape Health Services?
If you have not heard from an Outer Cape Health Services Referral Coordinator within 10 business days, please contact us at 774-209-3233.
What if I need an Out-of-Network referral?
Your insurance may not cover out-of-network referrals. We advise that you contact your insurance company for information related to your coverage benefits. In most cases, your PCP will not provide an out-of-network referral.