Any time you are going to use a physician/facility that is not a Patoka Valley Health Care Cooperative network provider you need a written approval from the Cooperative.
An approved referral from the Cooperative insures you get the negotiated discount, the bill is paid at your highest benefit, and protects you against balance billing.
Balance billing is the practice of billing the patient for the difference between what the physician/facility charges for a test/procedure and what the insurance says is the maximum amount allowed. For example, if a physician charges $1000 for a procedure and the maximum amount allowed is $800, the patient would be billed for the $200 difference plus any amount remaining of the $800 not paid by the insurance.
The physician who is referring you to an Out of Network provider must send a written referral request to the Cooperative. This form can be found on our website at www.pvcooperative.com. All Patoka Valley Health Care Cooperative providers have the form in their office. The referral form MUST be completed by the physician! REFERRALS MUST BE RENEWED ANNUALLY! The processing of a referral takes approximately 48-72 hours, therefore it is important to obtain referral as soon as possible to allow for ample processing time.
You will receive written notification, via US Mail, that the referral has either been approved or denied. If you have not received that notification at least 2 days before your scheduled appointment, you should call the Cooperative.
If a referral is denied, the written notification will include the reason for the denial and the procedure for you to appeal the decision.
There may be financial penalties for either failure to obtain a referral or for using a physician/facility when a referral has been denied. You will need to check with the employer that provides your insurance or with the TPA that processes the claims. The telephone number for your TPA should be on the back of your insurance card.
You, a family member, or a friend should call the Cooperative as soon as reasonably possible, preferably within 48 hrs of a hospital admission.
DO NOT ASSUME THE HOSPITAL WILL DO THIS FOR YOU!