Hi all, sorry if this is not the right kind of question for this sub. For context, I have CF BCBS BlueChoice HMO health insurance in Maryland.
Last month I had biopsies taken for a suspected autoimmune disease diagnosis — the biopsies were taken by an in-network specialist at an in-network facility and were examined by the pathology lab at that facility; literally in the same building. I had a referral from my PCP for the procedure, with a note on the referral that it would include taking biopsies. CareFirst covered all of that, no problem. For the pathology lab work, I only owed $10.
However…The biopsies came back negative, which was a shock, so my PCP and the specialist who did the procedure both suggested that I see an even more experienced specialist for a second opinion. Okay fine, I get my PCP to write me a referral to see a new in-network specialist. This one wants the pathology team she works with to look at my biopsies again because she suspects they weren’t cut and/or examined correctly. The problem is that I see her at a satellite doctor’s office and the pathology lab that would be examining my biopsies is located at a totally separate hospital a decent drive away, though it’s in the same system as my specialist (both she and the pathology lab are part of University of Maryland Medical System). I confirmed that this pathology lab is in-network for me. CareFirst let me know that they will require pre-authorization for this process — my specialist submitted the paperwork for that a few days ago. What CareFirst will not tell me is whether I need a referral for the pathology lab specifically. They either didn’t understand the question when I called or didn’t care but all they would tell me is that I need to use LabCorp for lab work. I told them “Yes, but LabCorp doesn’t provide pathology lab work and CareFirst has previously covered my pathology lab work outside of LabCorp. So do I need a referral?” Same response. I tried asking for someone else to speak to but no luck.
If both my specialist and the pathology lab are in the same medical system do I need a referral for this in an HMO plan? I asked my PCP to send the pathology lab a special referral just in case but haven’t heard back on whether he will do so.
Thank you!
submitted by /u/diondeer
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Hi all, sorry if this is not the right kind of question for this sub. For context, I have CF BCBS BlueChoice HMO health insurance in Maryland. Last month I had biopsies taken for a suspected autoimmune disease diagnosis — the biopsies were taken by an in-network specialist at an in-network facility and were examined by the pathology lab at that facility; literally in the same building. I had a referral from my PCP for the procedure, with a note on the referral that it would include taking biopsies. CareFirst covered all of that, no problem. For the pathology lab work, I only owed $10. However…The biopsies came back negative, which was a shock, so my PCP and the specialist who did the procedure both suggested that I see an even more experienced specialist for a second opinion. Okay fine, I get my PCP to write me a referral to see a new in-network specialist. This one wants the pathology team she works with to look at my biopsies again because she suspects they weren’t cut and/or examined correctly. The problem is that I see her at a satellite doctor’s office and the pathology lab that would be examining my biopsies is located at a totally separate hospital a decent drive away, though it’s in the same system as my specialist (both she and the pathology lab are part of University of Maryland Medical System). I confirmed that this pathology lab is in-network for me. CareFirst let me know that they will require pre-authorization for this process — my specialist submitted the paperwork for that a few days ago. What CareFirst will not tell me is whether I need a referral for the pathology lab specifically. They either didn’t understand the question when I called or didn’t care but all they would tell me is that I need to use LabCorp for lab work. I told them “Yes, but LabCorp doesn’t provide pathology lab work and CareFirst has previously covered my pathology lab work outside of LabCorp. So do I need a referral?” Same response. I tried asking for someone else to speak to but no luck. If both my specialist and the pathology lab are in the same medical system do I need a referral for this in an HMO plan? I asked my PCP to send the pathology lab a special referral just in case but haven’t heard back on whether he will do so. Thank you!
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