Our goal is for you to understand when referrals and authorizations are necessary and how to obtain them.
Be aware that these documents include medical and technical language. That's why it's important for you to review these policies with your health care provider if you have questions.
For some products, a referral is required before you can obtain services from a doctor other than your Primary Care Physician (PCP). A referral is the recommendation by a doctor for you to receive covered care from another participating doctor or facility. When your PCP wishes to refer you to a specialist, he or she will contact us. We will send you a letter confirming the referral.
Preauthorization means that you or the physician in charge of your care must notify us in advance of plans for you to undergo a specific course of care, such as a hospital admission, or complex diagnostic test.
In most cases, your doctor notifies us to preauthorize care. For some PPO products, however, you are responsible for notifying us for certain services. If you have a PPO product, please contact Customer Service at the number located on the back of your ID card for additional information specific to your contract.
Your benefits may be reduced if you or your doctor fail to obtain preauthorization for the services on the Preauthorization Requirements List.
You can receive medical services in a variety of settings - in the hospital, in your doctor's office, at home, etc. We want to make sure that you receive your medical care in the most appropriate setting. The services listed on the Outpatient Procedure List have been classified as most appropriately delivered in an outpatient setting (e.g. doctor's office or outpatient department of a hospital). If any of these procedures are performed while you are an inpatient in the hospital, you or your doctor must call us for permission before you go into the hospital.
Medication Preauthorization means that the physician in charge of your care must notify us in advance of plans for you to obtain certain medications. Your doctor or the pharmacy that you go to is responsible for making sure that the required preauthorization is in place. Your claim may be denied if your doctor or pharmacy fails to obtain preauthorization for the services on the Medication Preauthorization List.
The following services require clinical review preauthorization for commercial managed care products, Medicare, Child Health Plus and certain PPO products. Please review the column that applies to the member’s specific health benefit program regardless of place of service.