If you have a managed care insurance plan (HMO/POS), there are many regulations that you as a parent must follow in order to receive the maximum coverage for your child’s health care costs. It is your responsibility to follow the rules that your insurance company has set up. Obtaining the proper insurance authorization is necessary and must be received in advance of any health care you receive outside of Wheaton Pediatrics.
We at Wheaton Pediatrics are bound by the rules of your insurance company. We are not able to complete referrals for services that are not recommended by Wheaton Pediatrics, for procedures which were not first authorized by our doctors, or for procedures that are not medically necessary.
It is your responsibility to check with your managed care insurance plan and the specialist/facility to whom the referral is made, to verify specific requirements for the referral (authorization number, written referral, etc). Those requirements need to be forwarded by you to our referral department in advance of your appointment, in order for your specialist to be able to see you at your scheduled time.
Part of your responsibility in following your insurance company’s rules includes verifying that the specialist you are seeing or the facility you are going to is contracted with your insurance plan. Contracts between insurance companies and doctors change frequently. You can verify this information by calling the “800” number on the back of your insurance card.
In order to obtain proper insurance authorization, managed care insurance requires your child be evaluated by a primary care physician (PCP) in our office before you can see a specialist. Once you have been evaluated by the PCP, the provider will give you recommendations for a particular specialist. After you have verified that the specialist is contracted with your insurance, you can schedule an appointment. Please call our referral desk at that point at 630.690.7300, Ext. 225, to begin the referral process and provide the following information:
1. Your child’s name (including the spelling of the last name)
2. The reason for the referral (diagnosis)
3. The specialist’s name
4. The appointment date for the specialist visit
5. A phone number where you can be reached in the next 24 – 48 hours
6. The name of your insurance company and the product type
Procedures requiring approval from our office for managed care plans are:
1. Visits to a specialist
2. Emergency care or convenient care visits
3. Radiology (X-rays, MRI’s, CT Scans)
4. Any therapy service
Some procedures require advance approval from the insurance company, in addition to the referral. These include, but are not limited to:
1. Outpatient surgery
2. Hospital admissions
3. 23-hour hospital observation
4. Medical supplies and durable medical dquipment (in-home medical equipment)
5. MRI’s and CT scans
Please allow 3-5 days for referral processing. If you are unsure of what to do, please feel free to call the referral desk at 630.690.7300, Ext. 225.