In order to help keep costs as low as possible, many insurance plans have pre-certification requirements for specialist visits or advanced testing (such as CT scans) and/or prior approval requirements for certain medications. This means that an assigned primary care provider is the “gatekeeper” to these higher levels of service. This is a very common model in many HMO and similar insurance plans.
The Gallagher Student Injury and Sickness Insurance Plan also has referral requirements for students enrolled on the plan. This means that care outside of the Student Health Center requires an annual referral before the claim will be processed. Students can request the referral from their primary care provider at the Student Health Center by messaging that provider or calling Student Health at 615-322-2427. Students who do not have an established relationship with a primary care provider at Student Health can call 615-322-2427 to schedule a brief appointment for a referral request and/or to schedule an appointment to establish care with a primary care provider at Student Health. In many cases, students end up finding that Student Health may be able to fully meet their needs without the need for the outside referral and the costs associated with care outside of Student Health. Students who wish to maintain a relationship a primary care provider outside of Student Health are welcome to do that, but the insurance still does require an annual Student Health referral for those visits before the claims will be paid.
In the following cases, referrals are not required:
- Care that occurs when the Student Health Center is closed
- Medical Emergencies
- Medical care received when an Insured Student is more than 40 miles from the Vanderbilt University campus.
- Medical care received when an Insured Student is no longer eligible to use the Student Health Center due to a change in student status (for example, while a student is on medical leave of absence)
- Medical care for Insured Dependents
- Maternity, obstetrical and gynecological care
- Mental Illness Treatment and Substance Use Disorder Treatment.
Please see https:www.vumc.org/student-health/student-health-insurance for additional information, including FAQs and brochures for the Gallagher Student Health Insurance Plan.