In most health plans, your primary care doctor manages your care. This means that you need a referral from your primary care doctor for most other medical services. You may also need prior approval for the service from your medical group or health plan. An approval is also called an authorization. It is important to follow your health plan's rules about referrals and prior approval. If you do not follow the rules, you usually have to pay all of the cost of the service yourself.
You Usually Need a Referral and Prior Approval To:
- See a specialist, such as a cardiologist if you have a heart problem.
- Have a procedure, such as removal of a skin cancer.
- Have special tests, such as a colonoscopy.
- Have surgery, such as a hip replacement.
- Be admitted to the hospital, except in an emergency.
- Get a second opinion from another doctor about treatment.
- See a doctor who is not in your health plan's network.
You Do Not Need a Referral and Prior Approval To:
- Go to any hospital in an emergency.
- See an OB-GYN in your health plan's network for pregnancy or routine gynecological (female) care.
More Information About Prior Approval
- If your health plan does not approve a service you or your doctor requests, you can file a complaint with your health plan.
- Prior approval is also called prior authorization or preauthorization.
- Usually, your medical group or health plan must give or deny approval within 3-5 days.
- If you need an urgent appointment for a service that requires prior approval, you should be able to get the appointment within 96 hours.
- Be sure you understand exactly what services are covered by a referral and prior approval. For example, if you get a referral to a specialist and the specialist recommends tests, you may need another referral and prior approval for the tests.
- Your Evidence of Coverage tells you more about referrals and prior approvals.
- Ask your primary care doctor to explain how to get prior approval. Or call the customer or member services phone number on your Membership Card.