Rockford Health Plans - FAQ

Rockford Health Plans - FAQ

What should I do if I need to see a specialist?

Does Rockford Health Plans HMO need to approve my referral?

Are there any situations when I do not need a referral from my primary care physician to see a specialist?

If I visit a participating obstetrician/gynecologist or vision provider according to the above schedule, is there a copayment?

Does Rockford Health Plans HMO cover oral surgery, and if so, do I need a referral from my primary care physician?

What should I do if I need to see a specialist?
First, see your primary care physician, who can meet most of your health care needs. If your doctor determines that you need additional medical care, you will be referred to a specialist who participates in the Rockford Health Plans HMO network. The specialist will likely be from within the same medical group or network as your primary care physician if one is available.

Does Rockford Health Plans HMO need to approve my referral?
Yes. Each time your primary care physician refers you to a specialist, the referral is reviewed by medical staff at Rockford Health Plans HMO. Do not make an appointment with a specialist until you are notified by Rockford Health Plans that your referral has been approved.

When your need to see a specialist is urgent, your physician can obtain a referral by telephone.

The type of medical care, the number of visits you are approved for, and the length of time for which your referral is valid will be determined. The number of visits depends on your specific condition and your medical needs. You can call the member services department if you have any questions about referrals.

Are there any situations when I do not need a referral from my primary care physician to see a specialist?
Members may receive covered care from any participating vision provider for routine eye exams once every 24 months at ages 18 through 64, and once every twelve months at age 17 and younger or 65 and older.

Members who have diabetes may receive a retinal eye exam from a participating provider once every twelve months regardless of age.

Women do not need referrals from primary care physicians to see obstetricians/gynecologists who are participating in the Rockford Health Plans HMO network, or to see participating family practice physicians for obstetric or gynecological care. If your primary care physician is a member of Freeport Regional Health Network, your obstetrical and gynecological care must also be provided by a physician from Freeport Regional Health Network.

If I visit a participating obstetrician/gynecologist or vision provider according to the above schedule, is there a copayment?
In most cases, members will pay an office copayment. Please check your Schedule of Benefits for that information about your specific health insurance plan or call the member services department for more information.

Does Rockford Health Plans HMO cover oral surgery, and if so, do I need a referral from my primary care physician?
Rockford Health Plans HMO does cover some oral surgery. Call the member services department to verify your covered benefits. If you do have oral surgery coverage, you will need to contact your primary care physician for a referral before you schedule surgery.