Referrals and Authorizations Did you know that“ referral” and“ authorization” mean different things?
Referrals and Authorizations Did you know that“ referral” and“ authorization” mean different things?
REFERRAL AUTHORIZATION
What it is: Your PCP’ s recommendation for you to see a specialist or receive specialized care. Most specialists require a referral before scheduling an appointment. Senior Care Plus does not require a referral for payment.
What it is: A check by the health plan to make sure treatments, tests, or medicines are safe, necessary, and effective. Some services need prior authorization to be covered.
How it works: 1. Your PCP sends a referral and your medical records to the specialist’ s office.
2. Specialist office may call you to schedule, or you can call them. Processing time may vary.
3. After your visit, the specialist develops a treatment plan, which may need prior authorization.
How it works: 1. The provider submits an authorization request with treatment details and supporting medical records.
2. A nurse, pharmacist, or doctor reviews the request, your records, and plan benefits to see if it’ s medically necessary.
3. You and your provider are notified in writing of the decision.
Key note: Referrals help your PCP and specialists coordinate care.
Key note: Prior authorization ensures care is safe and meets standards, but does not guarantee payment. Coverage depends on eligibility, deductible and plan rules.
MEDICAL NECESSITY Services / Treatment must be needed to prevent, diagnose, or treat a condition. They must also meet nationally recognized standards of care to be approved.
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