Before seeing a gastroenterologist, check three things with your insurance: whether you need a referral, whether the specialist and procedure are covered, and whether prior authorization is required. Sorting these out early prevents surprise bills and delays. This plain-English guide is written for patients of Digestive Health Specialists, the Scottsdale practice behind DigestiveAZ.com, and explains each step.
Key takeaways
- A referral is a written order from your primary care provider to see a specialist.
- Prior authorization is your plan’s approval before certain services, such as some procedures.
- Screening and diagnostic colonoscopies can be billed differently; ask before you book.
- Your insurer and the practice’s billing team are the right sources for cost questions.
Referrals explained
A referral, as HealthCare.gov defines it, is a written order from your primary care doctor to see a specialist or get certain services. Many HMO-style plans require one before they will pay for a specialist visit, while many PPO plans do not. Your plan documents or member services line will tell you which applies.
If you need a referral, ask your primary care office to send it before you call to book, and keep a note of the date and reference number.
Prior authorization explained
Some services need your plan’s approval in advance. HealthCare.gov describes prior authorization as a decision by your insurer that a service is medically necessary before you receive it. For GI care, this most often applies to procedures, imaging or certain medicines, including some infusion therapies used for inflammatory bowel disease.
The practice usually submits the request, but it helps to ask whether it has been approved before your appointment date.
Common GI billing terms
| Term | What it means for you |
|---|---|
| Copay | A fixed amount you pay for a visit or service |
| Deductible | What you pay each year before your plan starts sharing costs |
| Coinsurance | Your percentage share of costs after the deductible |
| In-network | Providers who have an agreement with your plan, usually lowering your cost |
| Facility fee | A separate charge that can apply for procedures at a surgical or endoscopy center |
Screening vs diagnostic procedures
How a colonoscopy is billed can depend on why it is done. A routine screening colonoscopy in someone without symptoms is often covered as preventive care, while a colonoscopy done to investigate symptoms, or one where a polyp is removed, may be billed differently. Rules vary by plan, so ask your insurer how your specific procedure will be processed. Our article on colon cancer screening at 45 explains when screening usually starts, and the upper endoscopy guide covers the other common procedure.
A step-by-step checklist
- Call your insurer or check your plan documents for referral and prior authorization rules.
- Confirm the practice and the endoscopy center are in your network.
- Ask your primary care provider to send a referral if needed.
- Book by calling (480) 563-5757, Monday to Friday, 8:00 AM to 4:30 PM.
- Before a procedure, ask whether authorization is approved and what costs to expect.
- Keep copies of referrals, approvals and statements in one folder.
Where to find billing information
The official website lists insurance and billing information under Resources, along with an online payments page and patient forms; our DigestiveAZ.com quick facts show where each tool lives. For anything specific to your account, contact the practice directly. If a bill looks unexpected, ask for an itemised statement and check it against your insurer’s explanation of benefits.
New patients may also find our first GI visit checklist useful, and you can learn about conditions the practice treats, such as IBD and IBS, in digestive conditions. More practical guides are collected in patient guides. This guide is general information; the practice and your insurer have the final word on your coverage.
Tips for avoiding surprise bills
A few habits make GI billing far more predictable:
- Write down the name of everyone you speak to at your insurer, with the date and a reference number.
- Ask whether separate bills are expected for the physician, the facility, anesthesia and any lab work.
- Request a cost estimate before planned procedures.
- Compare each statement with your insurer’s explanation of benefits before paying.
- Ask about payment plans if a balance is larger than expected.
If you were referred to the practice through Arizona Digestive Health, statements may show either name; our article on how DigestiveAZ.com and Arizona Digestive Health relate explains why. Your records and account belong to the same Princess Drive office.
When your plan changes
Coverage often changes at the start of the year or when you change jobs. Let the practice know about any new insurance card before your next appointment, and check whether existing referrals or authorizations need renewing under the new plan.
Frequently asked questions
Do I need a referral to see a gastroenterologist?
It depends on your plan. Many HMO-style plans require a referral from your primary care provider, while many PPO plans let you book directly. Check your plan documents or call member services before booking, and ask your primary care office to send the referral if one is needed.
What is prior authorization?
Prior authorization is your insurance plan’s approval, given before you receive certain services, that the service is medically necessary. For GI care it often applies to procedures, some imaging and certain medicines. The practice usually submits the request, but it is wise to confirm approval before your appointment.
Why might a screening colonoscopy cost more than expected?
If symptoms prompted the test, or a polyp is removed or biopsied, the procedure may be billed as diagnostic rather than preventive, which can change your share of the cost. Rules differ between plans, so ask your insurer how your procedure will be processed beforehand.
Who do I contact about a bill?
For questions about a bill from the practice, contact Digestive Health Specialists using the billing details on its official website or by calling the office. For questions about what your plan paid or denied, contact your insurer and refer to your explanation of benefits.
This article is general information, not medical advice. For personal care, contact your clinician or call (480) 563-5757.
