Referral Requirements
If you are enrolled in The Columbia Plan, your primary care provider is your Columbia Health Medical Services clinician and your initial mental health provider is at Counseling and Psychological Services (CPS).
Except for visits to a hospital emergency room or an urgent care facility, referrals from your Medical Services or CPS providers are required for most off-campus services for in-network coverage. Providers at Medical Services and CPS offer referrals once an evaluation and/or treatment plan has been completed.
If you elect to seek off-campus services without a current valid referral, you will be charged at an out-of-network rate and accept responsibility for the higher out-of-pocket costs.
Note: ColumbiaDoctors practice groups are not part of Columbia Health and are considered an off-campus provider. You need a referral from your on-campus Columbia Health provider to see these specialists.
What is a referral?
A referral is a written or electronic order from your on-campus provider to see an off-campus specialist for a specific medical or mental health service.
Referrals are required by many health insurances companies to ensure that members are seeing the appropriate providers for their treatment. Referrals must be issued prior to an off-campus appointment and cannot be backdated.
When is a referral required?
- Before an initial visit with an off-campus provider or specialist in New York City.
- For a follow-up visit with an off-campus provider after an emergency room or urgent care visit. You are required to get a referral from a Columbia Health provider. Aetna will not accept referrals from a non-Columbia Health provider, including emergency room and urgent care providers.
Even with a referral, students will be responsible for copays and possible additional charges when seeing an off-campus provider. Be sure to review the plan materials or consult with an Insurance Specialist at Columbia Health with any questions.
When do referrals expire?
For medical conditions, referrals expire on the last day of the plan year, August 14. If you need continued treatment with an off-campus specialist, please schedule an appointment with your Columbia Health provider to discuss the referral renewal.
For mental health conditions, referrals to off-campus counseling and psychological services are valid as long as the student remains continuously insured by the Columbia Plan. A referral is required prior to most initial visits with a specialist (see exceptions below).
When is a referral not required?
A referral is not required under the following conditions, though Columbia Health providers can assist in finding appropriate services:
- When medical or mental health care is obtained 50 miles or more away from the Morningside campus. Students will be covered for primary care, as well as other services, by the Aetna network of participating providers.
- Off-campus mental health services do not require a referral for spouses/partners.
- Prenatal and obstetric care.
- Elective termination of pregnancy.
- All services for dependent children.
- One baseline mammogram for women aged 35-40, one per year thereafter for women age 40 and older. Additional coverage may be provided pending a person’s personal and family history of breast cancer.
- One annual routine Pap smear screening and office visit. Additional testing will be billed according to the plan’s policy.