Referral FAQ for Students with the Extended Insurance Plan (SEIP or AEIP)
What is a referral?
When is a referral made?
How do I know what services are available at MIT Medical?
How do I know what services are covered under my benefit
plan?
To whom will I be referred?
Will I be referred to a specific clinician?
What are my responsibilities in the referral process?
How and when will I learn if my referral request has
been approved?
Once approved, for how long is a referral valid?
How does the MIT Health Plans Office decide whether
or not to approve a referral request?
What does “conditionally covered” mean?
What is an initial determination review?
What if a referral request is denied?
What is my financial responsibility if I am referred
for services outside of MIT Medical (including physical
therapy at the Z Center)?
What is a deductible?
What is coinsurance?
What is a copayment?
What is a referral?
A referral is a request from a care provider to the MIT Health Plans to approve services outside of MIT Medical. A provider's suggestion that a patient may need outside services is not a guarantee of health plan coverage. If your provider suggests outside services, you may want to ask them if they are submitting an official referral request on your behalf.
When is a referral made?
A care provider makes a referral request when they determine that a patient needs medical services that are not available at MIT Medical. Referrals are required for coordination of care only and do not guarantee coverage.
How do I know what services are available at MIT Medical?
For a complete list of MIT Medical’s offerings, please refer to the MIT Medical Services Directory. You may also contact Claims and Member Services at 617-253-5979 about services provided at MIT Medical.
How do I know what services are covered under my benefit plan?
See the Student Health Plan Overview or Summary Plan Description, or contact Claims and Member Services at 617-253-5979.
To whom will I be referred?
All referrals are made to a Blue Cross Blue Shield (BCBS) PPO provider.
Will I be referred to a specific clinician?
Sometimes your care provider will refer you to a specific outside clinician. At other times, the provider will refer you to a medical facility or center, and the specific clinician will be determined when you make the appointment. If you are referred to sleep centers, pain clinics, surgical day centers, Boston IVF, or Reproductive Sciences, we need to know the name of the specific clinician you will see. Contact your MIT Medical care provider after making your appointment at one of these facilities, and let your provider know the name of the clinician you’re going to see.
What are my responsibilities in the referral process?
- You must receive approval from the MIT Health Plans Office before seeing an outside clinician. Your MIT Medical care provider may make the appointment for you or may suggest that you contact the outside clinician to schedule an appointment. In either case, you must make sure you have received approval from the MIT Health Plans Office before going to the appointment or receiving any services from the outside clinician.
- The MIT Student Extended Insurance Plan covers four medically necessary office/urgent care visits outside of MIT Medical per calendar year. You are responsible for a $25 copay and 20 percent coinsurance for each of the four covered visits. You are responsible for keeping track of your annual number of visits. Once you reach your annual limit, you will be responsible for the entire charge for any subsequent visits during that calendar year.
- If you schedule the appointment yourself, you must contact your MIT Medical care provider with the scheduled date of the appointment and the outside clinician's name, address, and phone number.
- For occupational therapy, physical therapy, and speech therapy services, you must contact your MIT Medical care provider to tell the provider the scheduled "first date of service" (the date of your first therapy session).
- Ask the outside clinician to give your MIT Medical care provider periodic updates on your health status.
- Contact your MIT Medical referring provider if the consulting clinician refers you to another clinician. In that case, a new referral request must be submitted, and you must receive approval from the MIT Health Plans Office before seeing a new clinician.
How and when will I learn if my referral request has been approved?
- You will receive a letter informing you of the decision within seven business days. To find out the results of the decision sooner, you may call Claims and Member Services (617-253-5979) five business days after the referral request has been submitted.
- Occasionally, a decision is deferred because the MIT Health Plans Office must wait to receive additional clinical information. If this happens, a decision may take longer than five business days. You will receive a letter within five business days to let you know that the decision has been deferred.
Once approved, for how long is a referral valid?
Most referrals are valid for one year or until your insurance expires (whichever comes first). Occupational therapy, physical therapy, and speech therapy referral services must be completed within the calendar year. If you need to continue treatment into the new calendar year, contact Claims & Member Services at 617-253-5979.
How does the MIT Health Plans Office decide whether or not to approve a referral request?
Referral requests are reviewed by Health Plans Claims and Member Services to determine if the requested service is a covered benefit and if the service is available at MIT Medical. Referrals for regularly covered services (this includes most diagnostic tests) made to Blue Cross Blue Shield (BCBS) PPO providers are routinely approved within two business days.
Requests for outside services that are available at MIT Medical or requests for coverage of conditionally covered services require review by both the MIT Health Plan’s clinical reviewer and by Claims and Member Services. The clinical/administrative review will determine if the requested service is a "covered benefit" under your health plan and will evaluate the medical necessity of the service. Initial determinations on these requests are completed within five business days.
What does “conditionally covered” mean?
"Conditionally covered" refers to certain services or medications that may be covered only if a member meets specific medical criteria. A sleep study is an example of a conditionally covered service. Gastric bypass is another example of a conditionally covered service.
What is an initial determination review?
An "initial determination review" refers to the process the MIT Health Plans Office uses in its first consideration of requests for coverage for conditionally covered services. An initial determination review may result in a request being approved or denied.
What if a referral request is denied?
If an initial determination review results in denial of the referral, you have the right to appeal the decision. The letter you receive about the initial determination denial includes the justification, or reason, for the denial. The letter will also include information on your right to appeal the decision and the process for starting the appeal.
What is my financial responsibility if I am referred for services outside of MIT Medical (including physical therapy at the Z Center)?
- For occupational therapy, physical therapy, and speech therapy, a $25 coinsurance will apply. Coinsurance rates will be 20 percent for visits 1–16, and 50 percent for visits 17–24.
- For office visits, a $25 copayment and a 20 percent coinsurance will apply. Coverage is limited to four office visits per calendar year. Coinsurance does not apply to out-of-pocket maximum.*
- For diagnostic studies (e.g., CT scans, MRIs), 10 percent coinsurance will apply.
* For a definition of, and more information about, “coinsurance” and “out-of-pocket maximum,” see the Student Health Plan Overview (PDF).
What is a deductible?
A "deductible" is a fixed dollar amount that you must pay before benefits are provided for certain covered services.
What is coinsurance?
"Coinsurance" is the amount that you must pay for certain covered services and is based on a percentage of either the provider's actual charge or the provider's allowed charge.
What is a copayment?
A "copayment" is a fixed dollar amount you must pay for certain covered services.
If you have additional questions about referrals, coverage, or benefits, please contact Claims & Member Services at 617-253-5979 or mservices@med.mit.edu.
Resources
Student Health Plan Overview (PDF)
MIT Student Medical Plan Summary Plan Description (PDF)
MIT Student Extended Insurance Plan Summary Plan Description (PDF)
Related Links
Student and Family Enrollment Form (PDF)
Affidavit of Spousal-Equivalent
Partnership
MIT Medical Services Directory
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