If you need to provide certain types of covered services or supplies you need a referral or Authorization for specific services and care to get paid for the services you provide.

Referral and Authorization Services

The referral is the process of sending a patient to another practitioner (ex. specialist) for consultation or a health care service that the referring source believes is necessary but is not prepared or qualified to provide. When primary care physician will refer a patient to a participating specialist or a health care service provider if he or she cannot personally provide the care the patient needs. Many referrals do not require an authorization number. But it’s important to confirm the referral details.

Authorization, also known as pre-certification, is a process of reviewing certain medical, surgical, or behavioral health services to ensure medical necessity and appropriateness of care before services are rendered. The review also includes a determination of whether the service being requested is a covered benefit under your benefit plan. Authorizations are only required for certain services being rendered (Prior Authorization is required) Authorizations are subject to a member’s eligibility, enrollment status, and covered benefits.