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HealthCare Frequently Asked QuestionsReferrals
A specialist is a physician with extensive education, professional training and certification in a specific type of care. Examples of types of specialists are surgeons, cardiologists, psychiatrists and ophthalmologists. A referral is a request from your Primary Care Physician (PCP) for you to receive care from a specialist or other treatment such as hospital admissions, lab or x-ray services or outpatient procedures. If you participate in an Open Access plan, you do not need a referral from your PCP to see a specialist. For all network plans, your PCP will also obtain authorizations as required for other treatments such as hospital admissions, lab or x-ray services or outpatient procedures. If you need the attention of a specialist, your PCP will provide you with a referral. He or she will also notify your health plan, help you choose a specialist and arrange the office visit. Routine referrals are usually handled within 10 days. In urgent situations, the referral can be approved on the same day, by phone. Do I need a referral for each visit for ongoing treatments? When you receive a referral from your PCP it authorizes specific services. Referrals are valid for a set number of days; your PCP will explain. If the specialist determines you need more visits or another referral beyond the authorized period, he or she will work with CIGNA HealthCare or your PCP to authorize the care. You should contact the Customer Service number on your CIGNA HealthCare ID card before receiving additional care to make sure the services are covered. Do I need a referral to see my OB/GYN? Generally, no. CIGNA HealthCare plans have adopted an "open access" policy for women's health care. You can visit your CIGNA HealthCare participating OB/GYN for covered obstetrical or gynecological services without a referral from your PCP. Some employer plans may differ, however, so check your plan for details. If my OB/GYN refers me to a specialist, do I need a referral from my PCP? Yes, Unless you participate in an Open Access plan, your PCP is still responsible for making referrals to specialists. If you participate in an Open Access plan, no PCP referral is required to see participating specialists. Do I need a referral to go to a hospital? In an emergency situation, you don't need a referral or any other authorization to go to an emergency facility; seek appropriate care immediately. (See: What do I do in an emergency?) For planned hospital stays, prior to your admission you or your doctor must call the number on your ID card to request "pre-admission certification." Pre-admission certification verifies the medical necessity for your hospital stay. |
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