Referral Management

Keeping Care Local

Pictured (l-r): 1st row – Michelle Costanza, Ann Cabral and Judith O’Leary; 2nd row – Jean Servizio, Krista Jones, Stacey Keough and Louis Di Lillo, MD; 3rd row – Dianne Dobbins, Stacey Begonis and Meg Doyon

The Referral Management Department serves as a resource to our Northeast PHO (NEPHO) membership by providing administrative simplification in referral processing while maintaining health plan specific contractual obligations.  We offer the full range of referral management services to interested practices.

The Referral Team also processes out of PHO network referrals for all of our providers. One of our goals is to retain care within the PHO referral circle.  We work closely with our Medical Director, Dr. Lou Di Lillo, and our providers and their office staff to re-direct out of PHO referral requests to in-PHO providers.  Through education and adherence to referral management protocols, we help keep care local and promote both provider and patient satisfaction.

 

The Referral Team is here to help you and your patients:

Fax Number: 978-236-1611

Ann Cabral
Manager, Referral Services
978-236-1758
Ann.Cabral@Lahey.org

Michelle Costanza
Referral Lead
978-236-1748
Michelle.J.Costanza@Lahey.org

Krista Jones 
Referral Lead
978-236-1634
Krista.Jones@Lahey.org

 

Stacey Begonis
Referral Coordinator
978-236-1754
Stacey.Begonis@Lahey.org

Meg Doyon
Referral Coordinator
978-236-1729
Margaret.M.Doyon@Lahey.org

Jean Servizio
Referral Coordinator
978-236-1737
Mary.J.Servizio@Lahey.org

 

Northeast PHO Referral Mangement Policy

In an effort to reduce the number of patients seeking care outside of the Northeast PHO (NEPHO) network, the following referral management process has been put into place:

  • Requests for specialty care referrals outside of the NEPHO network for BCBS, Fallon, Harvard Pilgrim (HPHC), Tufts and Tufts Medicare Preferred (TMP) HMO patients will be subject to Medical Director review.
  • The following criteria must be documented in order for an out-of-PHO (OOPHO) referral request to be approved:
    • Pre-existing relationship – clinical notes will be required to support this request
      • One calendar year
      • Follow up to current surgery or complication of current surgery or therapy
    • Access to care – refer to PHO Specialty Access Guidelines
    • Services not in NEPHO network – clinical notes will be required to support this request
    • Coordination of care – clinical notes will be required to support this request
    • ER follow up – clinical notes will be required to support this request
    • Second opinion – requires Medical Director review and documentation
  • In-PHO Orthopedic Policy
    • Members must see an in-PHO orthopedic specialist prior to being referred to an out-of-PHO (OOPHO) or tertiary orthopedic specialist.
  • Pediatric Referral Rules
    • Referrals for the following pediatric specialties will be approved without PHO review:
      • Cardiology
      • Endocrinology
      • Gastroenterology
      • Nephrology
      • Neurology/Neurosurgery
      • Pulmonology
      • Rheumatology
      • Urology
    • Pediatric orthopedic referrals must be in-PHO excluding the following reasons:
      • Scoliosis
      • Malignant tumors
      • Congenital anomalies/issues
      • Club feet
      • Growth plate fractures for patients under 24 months
  • Referrals for the following services will not be subject to review:
    • Chiropractic care
    • Optometry
    • Physical therapy
    • Occupational therapy
    • Speech therapy