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REFERRALS QUESTIONS
and ANSWERS Question: What is a
referral? Answer: Any time
you are going to use a physician/facility that is not a Patoka Valley Health
Care Cooperative network provider you need a written approval from the
Cooperative. Question: Why do I need a
referral? Answer: An approved
referral from the Cooperative insures you get the negotiated discount, the
bill is paid at your highest benefit, and protects you against balance
billing. Question: What is balance
billing? Answer: Balance
billing is the practice of billing the patient for the difference between
what the physician/facility charges for a test/procedure and what the
insurance says is the maximum amount allowed. For example, if a physician charges $1000 for a procedure
and the maximum amount allowed is $800, the patient would be billed for the
$200 difference plus any amount remaining of the $800 not paid by the
insurance. Question: How do I get a
referral? Answer: The
physician who is referring you to an Out of Network provider must send a
written referral request to the Cooperative. All Patoka Valley Health Care Cooperative providers have
the form in their office. Question: How will I know
if the referral has been approved? Answer: You will
receive written notification, via US Mail, that the referral has either been
approved or denied. If you have
not received that notification at least 2 days before your scheduled
appointment, you should call the Cooperative. Question: What do I do if
the referral is denied? Answer: If a
referral is denied, the written notification will include the reason for the
denial and the procedure for you to appeal the decision. Question: What happens if
I do not get a referral or I decide to go ahead and see an out-of-network
provider when the referral was denied? Answer: There may
be financial penalties for either failure to obtain a referral or for using a
physician/facility when a referral has been denied. You will need to check
with the employer that provides your insurance or with the TPA that processes
the claims. The telephone number for your TPA should be on the back of your
insurance card. Question: What should I
do if I have an unscheduled admission to an out-of-network hospital? Answer: You, a
family member, or a friend should call the Cooperative as soon as reasonably
possible, preferably within 48 hrs of a hospital admission. DO NOT ASSUME THE HOSPITAL WILL
DO THIS FOR YOU! |