Patient’s Frequently Asked Questions about Referrals

Patients often have many questions on the referral process.  Below are some answers to many common questions on how the referral process works.  Winchester PHO strives to refer patients to the trusted specialists in our network, with whom our primary care providers are familiar with.

What are the benefits of staying in the Winchester PHO network?

By choosing to stay in-network, you are allowing your primary care physician to provide you with better coordinated care with other network providers.  Depending on your insurance plan, staying in-network provides you with direct access to specialists without the need for a referral authorization.

How do I obtain a referral?

In non-emergency situations, the first step in obtaining a referral is contacting your PCP to determine if specialty care is necessary.  If so, you will be referred to a specialist within our Winchester Physician Hospital Organization or broader network if the situation requires a provider with specific medical expertise.

I’m in an HMO plan. What do I need to know about getting covered services?

 As a member of a health maintenance organization (HMO) plan, you need to understand the basics of how to use your plan so that you know how your health care services are covered.

This includes understanding that:

  1. You must select a primary care provider (or PCP) to coordinate your care.
  2. If you see a specialist, you must have a referral from your PCP. (If you see a specialist without a referral from your PCP, you may be responsible for the entire bill—not just a copayment or deductible.)
  3. If you see a specialist, you may be responsible for paying out-of-pocket for services that have not been approved, arranged, or provided by your PCP.

Please remember that you are responsible for confirming with your Health Plan if the services provided to you will be covered and to ensure that necessary referrals or authorizations are obtained before your visit. Our practice works with your health plan to obtain referral authorizations on your behalf, but the ultimate responsibility is yours. You are also responsible for paying for covered services that are subject to your deductible, if you have one, until your deductible is satisfied.

Can I self-refer to a specialist?

Before consulting with a specialist, it is very important to schedule an initial visit with your Primary Care Physician (PCP).  Your PCP works within a strong network of providers with whom they have established relationships.  Seeing providers within this network guarantees high-quality, efficient and coordinated care.

I’ve been seeing the same specialist outside of the Winchester PHO network for several years, and now I have been referred to someone I don’t know. Why can’t I continue to see the same doctor?

We suggest specialists in the Winchester PHO referral circle so that we can better coordinate your care and advocate for our patients. Additionally, there are benefits for the patient in seeing a specialist with whom their PCP has an established relationship and trust.  This enables a high degree of coordination and timely communication.  If there are services that we are not able to offer in Winchester PHO or through our greater Beth Israel Lahey Health partners, we will work with you to make sure you are receiving the proper care.

Do I have second opinion benefits?

You do have second opinion benefits under your HMO plan—and this would be coordinated through your PCP office using the qualified providers within the Winchester PHO referral circle.

We will work together with you to discuss your needs and expectations, and then determine which specialist you should see.

What if I am out of my coverage area and need an insurance referral?

Coverage for out-of-area services varies by insurance carrier and plan.  It is always best to contact your insurance company prior to receiving non-emergent care.