When exploring treatment options for allergies, one question that comes up is “do I need a referral for allergy testing?” This is a straight forward question, but like most questions in healthcare, the answer is not straight forward.
First, what is a referral?
A referral means the patient is being referred by their primary care doctor, to another doctor who is not their primary care doctor. Sometimes a referral can be as easy as the doctor sending the patients information to the new doctor with information on why the patient is being referred. Other times, the referral has to be submitted to the insurance company and the insurance company has to approve the referral before the patient can be seen. This can take several days and can be a burden for the referring physician to process the referral, so patience is required. The difference between the two types of referrals is drastic and it is important to understand what your insurance plan requires. The easiest way to find out what your plan requires is by calling your insurance company and asking, although some doctors offices (such as Grace Medical & Allergy) can do this for you. If your plan requires a referral, you have to then ask your primary care doctor to submit the referral, either to the insurance company or to the new physician, whichever your insurance plan requires. Once the referral is sent and/or approved by the insurance company, you can see the new physician and the services will be covered according to your insurance plan.
Who needs a referral?
The main factor in determining if a referral or prior authorization is needed for allergy testing and treatment is in what type of insurance you have. If you have an HMO plan, you MAY need a referral, or the physician performing the services may need to also be your primary care doctor. If you have a PPO plan, you don’t need a referral in most cases and the physician doesn’t need to be your primary care doctor.
The confusion starts to happen with HMO plans. Just because you have an HMO plan, it does not mean you have to have a referral. And if you do need a referral, it may or may not need to be approved by the insurance company. If it does need to be approved by the insurance company, you have to wait for your primary care doctor to submit the referral to the insurance company, and wait for the insurance company to approve the referral. This can take days, or even weeks in some cases. It’s important to understand that this process is largely controlled by the insurance companies, and that doctors do not get reimbursed for the time spent processing a referral. This means that you will need to be patient during the process, and it’s a good idea to follow up every few days with your primary care doctor or insurance company to check the status of the referral.
In general, you need a referral if:
- You have an HMO plan
- Your plan requires you to choose a primary care provider
- You got your insurance plan through the Health Insurance Market Place
- You have Blue Cross Blue Shield Advantage
- You have a BCBS of TX plan starting with the letters: ZGN, VER, or ZGZ, VEL, or ZGP (among others)
In general, you don’t need a referral if:
- You have a PPO plan
- Services are being provided by your primary care provider
- Your plan doesn’t require you to choose a primary care provider
- You have out-of-network benefits
- You’re allowed to choose your own doctors
- You have traditional Medicare
- You have a federal employee insurance plan
Although the above information should give you a pretty good idea on if your insurance requires a referral for allergy testing and treatment, it’s always best to check with your insurance plan directly. Or, give us a call and we would be happy to do a free benefits check, which will give you an estimate of any out-of-pocket costs and tell you if a referral is needed or not.