Do You Need A Referral With Medicare

Requests For Diagnostic Imaging Services

Requests for diagnostic imaging services must have:

• the requesting practitioners full name, provider number or practice address
• the date of the request
• a description of the services requested.

Patients can choose a health professional and dont need to give a request to a specific practice. This also applies to electronic requests.

Read more about Requests for R-type Diagnostic Imaging Services on the Department of Health website.

Do I Need Referrals With Medicare

Medicare is a type of health insurance thats meant primarily for seniors in retirement. It typically takes the place of insurance provided through an employer and covers many medically necessary costs. If youre new to Medicare, then its important that you understand the different types of policies available and what sets them apart from each other.

How Can You Know What Your Costs Will Be Before A Colonoscopy

Ask your doctors office for an estimate of costs before you have a colonoscopy. The billing department can usually estimate an average cost based on Medicare and other private insurance you may have.

If for any reason your doctors office thinks Medicare wont cover your colonoscopy costs, theyre required to give you a special notice called an Advance Beneficiary Notice of Noncoverage.

Another consideration is if youll receive anesthesia for the procedure. Anesthesia providers bill costs separately from the doctor performing the colonoscopy.

If you have insurance that requires an in-network doctor, you may also need to ask whos providing the anesthesia to ensure that your costs are covered.

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Covered Preventive Services That Include Cost

• Diabetes self-management training, for people at risk of diabetes complications. Youll pay your Part B deductible if you havent already met it for the year , plus 20 percent of Medicares cost for the training.
• Diagnostic mammogram . Youll pay your Part B deductible if you havent already met it for the year, plus 20 percent of the cost of the screening.
• Digital rectal exam for prostate cancer .
• Glaucoma test if you are at risk. Youll pay your part B deductible if you havent already met it for the year, plus 20 percent of the cost of the screening. A copay may also apply if the screening is conducted in a hospital outpatient setting.

If youre enrolled in a Medigap plan, it may pay some or all of the Part B charges incurred for these services.

$0 Meal Delivery After An Inpatient Hospital Stay

Nutrition plays a critical role in maintaining optimal healthand we want to help! BCBSRI offers our Medicare Advantage members a meal delivery program through ILS Meals by Independent Living Systems. Youll get a weeks worth of meals delivered to your doorup to four times a yearwhen you get home from an inpatient hospital stay.

Home delivered meals offer a convenient and affordable way to recover once you are discharged from an inpatient hospital stay. The hospital discharge planner will help coordinate this benefit.

Benefits of the meal delivery program are:

• Meals delivered directly to your home following hospital stays
• Easy to heat in conventional ovens and microwaves
• Flash frozen for guaranteed freshness

• Nutritionally balancedcarbohydrate, sodium, fat, and portion controlled
• Menus designed and reviewed by registered, licensed dietitians and updated every six months to provide variety

13 Menu types to meet your unique needs

*Indicates heart healthy meal

• Prepared in adherence to Jewish law
• Gluten free diabetic*Excluded to control for carbohydrate content
• Gluten free*Contains less than 20 ppm gluten per meal

For more information on the meals program, call Independent Living Systems at 833-853-8946 and provide your BCBSRI Member ID number. Call Monday through Friday 8:00 a.m. to 6:00 p.m. Deliveries are made Monday through Friday only.

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Do I Need A Referral With A Bcn Advantagesm Plan

Who is this for?

BCN Advantage members who want to know if they need a referral to see a specialist. And if so, how to get one.

BCN Advantage doesnt require a referral for you to make an appointment with an in-network specialist. Some in-network specialists may need to confirm with your primary care physician that you need specialty care. Your PCP is the best resource for coordinating your care and can help you find an in-network specialist.

When you’re a member of one of our HMO-POS or HMO plans, you get the convenience of having one doctor who looks out for your health and coordinates your care.

Whether you have a bad cough, foot pain, or even a suspicious mole, see your primary care physician first. They might be able to give you the care you need. If not, they can refer you to a trusted specialist in your network, like a podiatrist or a dermatologist.

Tip: Women dont need a referral to see an OB/GYN for Pap smears and annual well-woman visits. But you’ll need to make sure you see an OB/GYN in your plan’s network.

If It Is A Diagnostic Screening

If your doctor finds and removes a polyp or other tissue during your colonoscopy, Medicare considers it diagnostic,12 even if you went in for a preventive screening. For diagnostic colonoscopies, you may pay coinsurance 20% of the bill plus a copayment if you get your colonoscopy in a hospital. Your Part B deductible does not apply.

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Are Any Medicare Managed Care Plans Available Where I Live

Currently, you can choose from three types of Medicare Managed Care:

• Cost Contract HMO
• Medicare Advantage PPO
• Medicare Advantage PFFS

These plans are available in selected counties of Indiana and it is important to know the differences between them.

Cost Contract HMO

Medicare will reimburse the plan for covered services you receive. You choose a primary care provider within the HMO network. When you stay within the network, you pay nothing except the plan premium and any small copayment amounts preset by the HMO.

You may also choose to use services outside of the network. When you choose to use a service or provider outside the Cost Contract HMO network, Medicare would still pay their usual share of the approved amount. You would be responsible for the Medicare deductibles and copayments. The Cost Contract HMO would not pay these. Cost Contract HMOs may enroll you if you don’t have Medicare Part A but have and pay for Medicare Part B. Cost Contract HMOs do not have to enroll you if you have end-stage kidney disease or are already enrolled in the Medicare hospice program.

Medicare Advantage PPO

This type of managed care plan maintains a list of preferred providers but lets you see doctors and hospitals outside the plan for an additional cost. If you choose to use a provider outside of the network, the plan will pay the same reimbursements as Original Medicare will unless you need emergency or urgent care.

Medicare Advantage PFFS

Factors That Affect Original Medicare Out

• Whether you have Part A and/or Part B. Most people have both.
• Whether your doctor, other health care provider, or supplier accepts assignment.
• The type of health care you need and how often you need it.
• Whether you choose to get services or supplies Medicare doesn’t cover. If you do, you pay all the costs unless you have other insurance that covers it.
• Whether you have other health insurance that works with Medicare.
• Whether you have Medicaid or get state help paying your Medicare costs.
• Whether you have a Medicare Supplement Insurance policy.
• Whether you and your doctor or other health care provider sign a private contract.

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Referrals & Prior Authorization

You can get many services without a referral from your Primary Care Provider . This means that your PCP does not need to arrange or approve these services for you. You can search for participating health partners using the Find a Doctor/Provider tool and schedule an appointment yourself. You can also check your provider directory for a list of participating health partners who offer these services.

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Prior Authorization For Services

When you need care, always start with a call to your doctor. Some covered services may require Prior Authorization by Louisiana Healthcare Connections.

A Prior Authorization decides if a service should be covered based on:

• whether the service is needed
• whether the service is likely to be helpful

Your provider will give us information about why you need the service. We will look to see if the service is covered and ensure it is medically necessary. We will make the decision as soon as possible based on your medical condition. Decisions are usually made within 14 calendar days. If you need to be admitted to the hospital for an urgent medical need, the decision will be made within two calendar days. If you require ongoing inpatient care, the decision will be made within one calendar day.

Your provider can tell you if a service needs a Prior Authorization. You can also call Member Services at 1-866-595-8133 to see if something needs Prior Authorization.

We will let your provider know if the service is approved or denied. If you or your provider are not happy with the decision, you can request a second review. This is called an Appeal. See the Member Satisfaction section of this handbook for more information.

NOTE: Emergency Room and post stabilization services NEVER require Prior Authorization. If there are any major changes to the Prior Authorization process, we will inform our members and providers right away.

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My Friend Recently Had A Procedure And His/her Prep Was Different Than Mine Why

Different physicians prefer different preparations for colonoscopy. You should follow the preparation instructions exactly as it was prescribed for you. Our physicians have a lot of experience in using the different colonoscopy preparations and have decided upon using SUPREPor MOVIPREP because of its low total volume and superior cleansing results. Any questions you have should be directed to our staff.

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Are There Any Protections If I Enroll In A Plan And Do Not Like It

In order to enable beneficiaries to try a Medicare Advantage plan, but still have the option of returning to Original Medicare, a number of protections are in place. These protections will enable beneficiaries, in certain situations, to try a plan, but then return to Original Medicare and a Medicare Supplement policy if they want to do so.

Under these protections, beneficiaries will have guarantee issue of a Medicare Supplement policy as long as they meet one of the following criteria. For eligible beneficiaries, companies which sell supplement policies will not be able to deny coverage, charge more, or exclude benefits. However, to receive these protections, beneficiaries must apply for a supplement policy within 63 days of disenrolling from the health plan, or within 63 days of the termination of the health plan.

A beneficiary would be eligible for the Medicare Supplement protections if they meet one of the following criteria.

Case #1

You are enrolled in a Medicare Advantage plan and one of the following happens:

• The contract between Medicare and the plan ends.
• The plan service area no longer covers the county where you live.
• You move out of the plan service area.
• There are violations by the plan.

Protection: In this case, you would get a guaranteed issue of a Medicare Supplement Plan A, B, C, or F from any company .

Case #2

Case #3

Protection: You are guaranteed to get any Medicare Supplement plan with any company .

Case #4

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Open Enrollment For Medicare Part D

Medicare Part D provides insurance protection for prescription drug costs. This protection in Medicare Part C, Medicare Advantage. Part D Prescription Drugs insurance can stand alone.

Some applicants prefer standalone coverage in Part D to getting a Medicare Advantage plan with prescription benefits in Part C.

Applicants must choose, they cannot have prescription coverage in both Part C and Part D. October 15 through December 7, is the open enrollment period for Medicaid Part D. Subscribers can take the below-listed actions during the Part D open enrollment period.

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If You Have An Hmo Or Other Plan That Requires You To Choose A Primary Care Doctor You Probably Will Need A Referral To See A Specialist This Is Not A Requirement With Original Medicare Though

Some private insurance plans require a referral to cover medical specialist care. A referral is an order from your primary care doctor to receive medical treatment from a doctor who specializes in your particular issue, such as a podiatrist to treat diabetic foot ulcers. If your plan requires a referral, your coverage may be limited if you just make an appointment with a specialist office without first receiving a referral from your primary physician.

Original Medicare does not require referrals, but some Medicare Advantage plans do. This article covers the restrictions on care present in Original Medicare, as well as how to deal with referrals under Medicare Advantage.

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Which Type Of Policy Is Right For You

At Turning 65 Solutions, we understand how important it is that you have the coverage you absolutely need and deserve. Thats why we will help you compare all your coverage options with Original Medicare and Medicare Advantage.

Regardless of your policy choice, were here to provide you with guidance. Making the right decisions can be challenging, especially when there are so many choices within Medicare. If youre feeling confused or overwhelmed, make an appointment to speak with someone at Turning 65 Solutions, were here for whatever insurance questions you have.

Does Medigap Require Referrals

Medigap plans, also known as Medicare Supplement Insurance, are private insurance plans that help cover your out-of-pocket costs. Due to the nature of these plans, specialists wont apply in any way, and you dont need a referral for any part of Medigap.

Because these plans are private, their costs will vary even though each plan’s benefits are standardized. Our Ultimate Guide to Medicare Supplement Insurance explains everything you need to know about Medigap.

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When And What Can I Eat After My Procedure

You can eat as soon as you leave the procedure facility. It is recommended that your first meal consist of relatively âlightâ food such as chicken soup, a turkey sandwich, or eggs & toast. Since you will have received sedation and your stomach will be empty, eating anything too rich or heavy might give you an upset stomach. You may resume your normal diet after the initial meal following your procedure.

What Is A Referral

A referral is a written order from your primary care doctor for you to see a specialist or to get certain medical services. The method of obtaining a referral depends on the type of insurance plan in which you are enrolled. Typically, your primary care physician provides referrals for care. It is important to note that if your plan requires a referral, you need to get the referral first. If you fail to obtain a referral, or do not obtain the referral prior to being evaluated by a physician or receiving medical services, then the plan may not pay for the services. It is important to note that for emergency and urgent care a referral is not needed. Additionally, if a Medicare Advantage plan is contracted with Medicare then the plan must cover all of the services that original Medicare covers except hospice care and some care in qualifying clinical research studies.

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Are There Any Exceptions

Yes, there are always exceptions to the rule! Specialists who provide behavioral health services, such as psychiatrists and psychologists, and are in your health care network do not require a referral from your PCP.

Women also do not need a referral to see an in-network obstetrician-gynecologist for routine care, such as Pap smears and mammograms. Also, visits that the insurance company considers an emergency may not need a referral.

Do You Need A Referral With Medicare Advantage

Medicare Advantage, also known as Medicare Part C, offers you a way to get your Medicare benefits through a private insurance company. Like other private health insurance plans, there is a lot more variety with Part C than with Original Medicare.

There are four different types of Medicare Advantage plans: HMO, PPO, PFFS, and SNP. Each plan type has different requirements for specialists and referrals, so its best to look at the type of plan you are interested in directly.

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Which Doctors Are Considered Specialists

A specialist is a physician with expertise in a specific area of medicine. Specialists usually have several years of advanced clinical training, in addition to general medical training. They may be certified by a governing board in their specialty and are required to keep their skills and knowledge current.

Specialists diagnose, manage and treat certain diseases, conditions, organs or body systems. Here are examples of different specialists:

If It Is A Preventive Screening

If you get your preventive colonoscopy from a healthcare provider who participates with Medicare and has agreed to accept assignment for Medicare-covered services, youll pay no copayment or deductible.11 Accepting assignment means that the provider agrees or is required by law to accept Medicare-approved amounts as payment in full. Most doctors who accept Medicare accept these payment terms, but its a good idea to confirm before you get services.

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