Referrals: Coordinating Your Care Effectively
Our goal at Harvard Vanguard is to make it easier for you to be healthy. Your primary care physician and medical team strive to listen to your needs and communicate with you effectively. We also seek to provide you with complete care, supporting your primary care physician with a wide range of services and specialists for the best treatment possible.
The following questions and answers will help explain how your medical team handles referrals to support your care:
- Is Harvard Vanguard a health plan?
- Where will I be referred for services and specialties?
- May I request a referral from my primary care physician after I have seen a specialist?
- What if I am referred to a specialist when I am at the emergency room or in the hospital?
- How do I request a referral for non-emergency care?
- How does my health plan (insurance) affect my referrals?
- What if I want to see a different specialist? Or already have a different specialist who does not practice at Harvard Vanguard?
- What if I am out of the area when I need a referral?
- Who do I call if I have a question about a referral?
- Contact your primary care physician's office to discuss your need for a referral based on your medical history and symptoms, to have a visit if needed, and to determine the right specialist for you to see. Even if your health plan does not require a formal referral, we suggest that you call your primary care provider to help you determine the best specialist for your care.
- Check with your health plan to understand what is covered and which fees will be your responsibility. If needed, the referral coordinator at your Harvard Vanguard practice can help you to determine what is covered by your health plan.
- Schedule the appointment with the specialist.
Is Harvard Vanguard a health plan?
Harvard Vanguard Medical Associates is not a health plan or insurance company. We are a large medical group, offering care across more than 35 specialties from more than 20 locations. We provide you with medical care and associated services and bill your health plan. The health plan pays for that care according to the rules of your policy.
Harvard Vanguard accepts most major health insurance plans, including Aetna, Blue Cross Blue Shield of Massachusetts, Fallon Community Health Plan, Harvard Pilgrim Health Care, Neighborhood Health Plan, Tufts Health Plan, and Tufts Medicare Preferred.
Where will I be referred for services and specialties?
Our primary care physicians have thoughtfully selected a preferred group of specialists, typically within Harvard Vanguard or a limited group of outside offices that they trust to provide you with high quality care. Your primary care physician works with this trusted group of specialists to coordinate your care using the established relationships and systems. Coordinating your care in this way ensures that your medications, labs, other test results and clinical notes are most easily seen by your treating physicians. This integrated approach has been proven important to overall care.
Note that not all of the specialists in your health plan's network are included in Harvard Vanguard's referral relationships. Therefore, it is not sufficient to know that a specialist accepts your health plan (insurance) to assume that you may be referred there. Please communicate with your primary care doctor regarding referrals to access the best care for your particular medical issue and to avoid the possibility that you may have to pay out of pocket for the specialty services.
May I request a referral from my primary care physician after I have seen a specialist?
Referrals should be requested prior to a visit to a specialist. If you see a specialist without the referral required by your health plan, it is likely that you will be responsible for the entire bill (not just a co-payment or deductible).
What if I am referred to a specialist when I am at the emergency room or in the hospital?
You should call your Harvard Vanguard primary care physician for a referral before seeing a specialist who is recommended by the emergency room and before following up with a specialist who you have seen at the hospital. This will best facilitate any follow-up care that is needed, as well as ensuring that the visits meet the requirements of your health plan.
How do I request a referral for non-emergency care?
Note that referrals are often needed for oral surgery, eye care other than to fit glasses, as well as other specialty care.
How does my health plan (insurance) affect my referrals?
The rules established by the health plans for referrals vary widely by insurance company and product, so you will have to contact member services at your health plan to understand what they require before they will pay for that test or specialist.
It is a good idea to understand the options and any restrictions that are offered by the health plan at the time when you are enrolling in the plan. For certain products, such as HMOs, your primary care physician will make the selection of specialists for you, working with you to understand your needs. Other products (e.g., PPO, POS) may allow you to pay additional costs to see a specialist that your physician did not select. If you choose to see providers outside of approved referrals, you may end up with responsibility for the entire bill (not just a co-pay or deductible).
What if I want to see a different specialist? Or already have a different specialist who does not practice at Harvard Vanguard?
Questions about specialists should be discussed with your primary care physician. Typically the physicians at Harvard Vanguard refer within our established relationships to provide you with the most complete and coordinated care. The need for a different opinion is best explored with your physician in a discussion about your individual needs and concerns. You may also be limited in your options by the restrictions of your health plan.
The exception to this is your choice of an obstetrician. By law in Massachusetts, women do not need a referral to select an obstetrician. Harvard Vanguard offers a wide range of obstetrical care, including at many locations certified nurse-midwives who work collaboratively with the obstetricians.
What if I am out of the area when I need a referral?
Coverage for out of area medical services varies widely by insurance company and product type (e.g., HMO, POS). Please consult your insurance company for specific information about services that are covered before seeking non-emergency care.
Who do I call if I have a question about a referral?
If you have a medical question about a referral, call your primary care physician's office.
If you are requesting information about whether a referral is covered by your health plan, please call Member Services at the phone number on your health insurance card.