Question:
What is the difference between a referral and a letter of medical necessity?
My doctor is getting together a referral, so that he can list all my illnesses. and I would like to know the difference if there is one. — tammy G. (posted on May 19, 2003)
May 19, 2003
it was to my understanding that a referal meant that a dr was sending you
to a specialist for further observation and a medically necesity letter was
to state and back up reasons why you needed treatment for your condition...
— Deanna Wise
May 20, 2003
A referral is when a doctor "refers" you to a specialist and
letter of medically necessity is a letter stating why your procedure is
medically necessary rather than cosmetic. Cosmetic is NEVER approved under
insurance however if you can prove it's medically necessary the insurance
will have to approve. Depending on your insurance company, this can be a
very complicated process trying to convince the insurance company. Trust
you me...I'm going through it now! Good Luck
— Jeanette D.
May 20, 2003
Tammy, the above posters are correct. If you have an HMO, the
"referral" is a process that the PCP office does because it's
required by your insurance. Some insurances require faxed referrals and
then approve or disapprove the referral within a certain number of days.
Many HMOs have gone to an automated telephone system, where the PCP office
enters in a PIN number assigned to the specialist they are referring you
to, a numeric code (called CPT code) that describes the type of visit
(usually consult and treat) and another numeric code (called ICD-9)that is
used for the diagnosis. If these numbers match a matrix contained in the
insurer's computer system, the referral is automatically granted, giving an
authorization number that the specialist puts on the claim form when
submitting the claim.
A letter of medical necessity is an actual letter, written by the
physician, describing why this procedure is necessary. The letter goes to
the Precert department at the insurance and is reviewed by an actual
person. Sometimes the precert person calls or writes the physician for
more information. Some insurances have an "automatic denial" for
the first letter and require more information upon appeal.
Most insurances, whether HMO, PPO or indemnity require a letter of medical
necessity for WLS.
And hey, physicians dislike this process as much as you do!
— Liz R.
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