What to Expect When you Need to Call Your Insurance Provider

When calling your insurance provider, you’ll typically speak with a Member Services Representative from your health plan’s customer service department.

*Tip: You can find the member services phone number on the back of your insurance card. For those with MassHealth, be sure to look at your ACO/MCO Health Plan Card.

Reasons to call your insurance and what to ask:

Check if a specific doctor, specialist, or service is covered

“Is Dr. [Name] covered under my plan?”

“Do I have a PCP listed?”

Confirm if you need a referral for a specialist

“Do I need a referral to see [specialist name]?”

“What happens if I want to see a different specialist?”

Find out what your co-pay or deductible will be for a visit or procedure

“What’s the co-pay or cost for this visit/service?”

Ask if a specific medication or treatment is covered under your plan

“Is this test/procedure (e.g., MRI, lab work, physical therapy) covered?”

Other questions that are helpful to ask:

“Do I need prior authorization before scheduling this?”

“Are there any limits on how many times I can get this service in a year?”

“If this isn’t covered, what are my options?”

Glossary:

Copay

  • A fixed, predetermined amount you pay for a specific service, such as a doctor’s visit or a prescription.
  • You typically pay this amount at the time of service.
  • Copays usually don’t count toward your deductible, but some plans may vary
  • Copays may continue to apply even after you’ve met your deductible, until you reach your out-of-pocket maximum.

Deductible

  • The amount you pay for covered healthcare services before your insurance starts to pay.
  • For example, if your deductible is $2,000, you’ll pay the full cost of your medical bills until they reach that $2,000 threshold.
  • Once you’ve met your deductible, your insurance will typically start paying a larger portion of your healthcare costs, often through coinsurance.
  • Some plans may have separate deductibles for medical and prescription costs.

Referral

  • Referrals ensure that patients see specialists who are best suited to address their specific medical needs and that the care is coordinated with their primary care physician.
  • Many health insurance plans, particularly HMOs and POS plans, require referrals for specialist visits to be covered. If you have a PPO, you may not always need a referral, but seeing an out-of-network specialist will likely cost more.
  • Your doctor will send the referral electronically or give you a form to take to the specialist. Once it’s approved, call the specialist and book your visit!
  • Tip: Always ask how long referrals are valid—some expire after 30-90 days!
  • Doctors can put in a referral, but that doesn’t mean it is scheduled.
  • Referrals are not needed for behavioral health services.

Resources:

  1. Emerson Financial Counseling
  2. Health Care For All MA
  3. Mass Health Representatives
  4. SHINE Program: If you are enrolled in Medicare, the Commonwealth of Massachusetts provides free information, counseling, and assistance to you and your caregivers through the SHINE Program (Serving the Health Insurance Needs of Everyone). Specially trained counselors ensure that Massachusetts residents with Medicare and their caregivers have access to accurate, unbiased, and up-to-date information about their healthcare options. For more information, visit the SHINE Program website.
  5. Massachusetts Health Connection Getting Started Guide
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