How Do Referrals Work?

Thank you for choosing us as a part of your health care team. We’re committed first and foremost to your health, and we’re here to serve as the center of your everyday care. Our role is also to coordinate any extra care you may need with our trusted team of specialists and providers through our affiliation with Lowell General Hospital. We pride ourselves on our collaborative relationships. When you need specialized care, we’ll work with you to identify the best doctor and provide a referral.

What is a Referral?

When you and your primary care physician (PCP) determine that you need specialized care, your PCP will “refer” you to a specialized provider from our trusted team. A referral is required if you have an HMO health plan before the health plan will cover these services. It’s important that the referral comes from us—not only because your plan requires it, but because your PCP, as the center of your care, needs to be involved and aware of the care you’re receiving, and to coordinate with you and your specialist on an ongoing basis.

Why Do I Have to Check with My PCP Before Seeing a Specialist?

Your PCP knows your history and overall health, so he or she is best qualified to help you decide if you should see a specialist. Even if your health plan doesn’t require a referral, your PCP may want to evaluate your care needs before you see a specialist, in order to coordinate your care. We’re committed to making sure you get the right care, at the right time, in the right setting—especially if you need to see a specialist.

How Do I Request a Referral?

Contact your PCP’s office to discuss your health situation. Together, you can decide if you need to see a specialist. If you need to visit a specialist, your PCP will help you choose the most appropriate doctor for the care you need. Be sure to have this conversation before you visit a specialist. If you see a specialist without a referral, you may be responsible for the entire bill (not just the copayment or deductible).

Where Will I Be Referred for Services and Specialties?

We rely on a trusted network at Lowell General Hospital, which includes a wide range of specialties to carry out your treatment plan. By referring you to specialists we know well, you, your specialist, and our group can work together to ensure you get high-quality, timely, and effective care. (Please note: Not all of the specialists in your health plan’s network are part of our group. It’s very important to always discuss your clinical condition and concerns with your PCP to determine together if a specialist visit is needed and which doctor is best for you).

Are There Times When I Don’t Require a Referral?

Because your PCP coordinates your care, you should always let our group know whenever you seek treatment of any kind. There are certain instances, however, when you don’t need a from your PCP in order to receive coverage from your health plan, including cases when you seek emergency medical care, covered annual gynecological exams, and other services require as result. For further details about the specific cases that don’t require a referral, please call the Member Services phone number on either the front or back of your insurance ID card.

After an Emergency Room (ER) Visit, Who Should I See for Follow-up Care If the ER Recommends Follow-up at Their Facility?

As the coordinator of your care, you should always contact your selected PCP about your emergency room visit. He or she will determine the best coordinated follow-up care for you.

How Do I Know If My Health Plan Require Referrals?

There are several ways to learn about your plan’s referral requirements: check your subscriber certificate provided by your health plan; visit your health plan’s website (if they have a website available); or call Member Service at the number located on the front or back of your insurance card. It’s essential that you fully understand your plan’s referral requirements, because if you don’t get a required referral prior to receiving non-emergency care, you may be responsible for the entire bill (not just a copayment or deductible).

Who Do I Call if I Have a Question About a Referral?

If you have a medical question about a referral, just call your insurance plan. If you need information about whether a service is covered or requires a referral by your health plan, please call your member service at the number on the front or back of your insurance ID card.