Managed Care Tips

Pre-authorization Referral Guidelines

Most PPO Managed Care Plans now require your Primary Care Physician (PCP) to obtain pre-authorization for selected diagnostic tests (e.g. CT scans, MRI scans, nuclear cardiac scans). In most instances, an office visit with your PCP will be required to establish clinical documentation justifying the referral.

HMO members must have a pre-authorized referral for every test or service not performed in our office; this includes, but is not limited to, specialist consultations and follow-up visits, laboratory tests, radiological tests, diagnostic tests, procedures, therapy referrals and elective hospitalizations. For example, if you were referred to a consultant who recommends an MRI scan and a follow-up visit, pre-authorization must be obtained for each of these new recommendations. Each HMO member is responsible for informing our office of any newly recommended services so that the referral process can be initiated. Per HMO guidelines, if you proceed without obtaining pre-authorization we cannot issue any retro-active referrals. This may result in denial of claims and significant out-of-pocket expense. For your convenience, you can call our office at 847-462-5100 and choose Option 4 to leave us a voice mail regarding new referral requests.

Once we receive authorization, we will contact you with all the information necessary to schedule your tests or appointments. Please be advised that the referral process may take up to 7 business days to complete, and at least one week advance notice is required for all referral authorizations.

Once you have been granted a referral authorization, you should schedule your appointment immediately, since most referrals are only valid for 30 days after issuance. Referral authorizations are extremely time-consuming, and failure to schedule your test or consultation within this time frame will not necessarily result in automatic re-issuance. In fact, most lapsed referrals will require another office visit in order to update the required documentation.

Finally, we have a contractual obligation with each insurer to refer our patients only to “in-network” physicians, facilities and ancillary service providers.


"Wellness" vs. "Diagnostic" Annual Exams

In the past, all complete physical examinations claims were submitted as "diagnostic" visits. This meant that when a patient was seen for their annual exam, specific diagnoses such as chest pain, headache or hypertension were submitted to the patient’s insurer in order to receive payment for services rendered.

In recent years, many insurance plans have started offering annual "Wellness" coverage. "Wellness" visits are considered preventive health care examinations, and the patient does not have to have a specific complaint or medical illness to justify the visit. A diagnosis of "Preventive Health Care" (V70.0) is used for claim submission. This distinction is important because many plans offering such coverage reimburse "Wellness" examinations at a higher rate, and often reduce or eliminate co-pays for preventive care visits. On the other hand, some insurers offer wellness plans with very limited coverage; they may only cover the physician’s examination fee, while excluding payment of common tests that previously were covered as part of a "diagnostic" physical. In this instance, billing the exam as "diagnostic" may be to your advantage whether you have "Wellness" coverage or not.

For these reasons, we highly recommend that you find out whether you have “Wellness” coverage prior to your scheduled physical. If you have "Wellness" coverage, you should also try to determine the extent of that coverage. Ask whether there is a fixed dollar amount allotted for “Wellness” exams, and try to determine the scope of your coverage. Ask if tests such as a CBC (complete blood count), CMP (chemistry panel), lipid panel (cholesterol profile), PSA (prostate cancer test), PAP smear (cervical cancer test), fecal occult blood test (colon cancer screening test) and EKG (electrocardiogram) are covered. If you are 50 years or older, will a screening colonoscopy be approved if your Physician recommends the test?

As a general guideline, virtually all HMO, United Health Care, and trade sponsored health plans have "Wellness" coverage, as do many Blue Cross, Aetna, Cigna, and Humana plans. Medicare currently has very limited "Wellness" coverage only for new enrollees during their first six months of coverage. If you do not have or do not know whether you have "Wellness" coverage, we will submit your claim using diagnostic codes. Please note that once your claim has been submitted, we cannot change it from "Wellness" to "Diagnostic" or vice versa.

If you have any questions regarding the above, please call our office during our regular business hours.