Referrals & Authorizations Explained


If your plan requires referrals to see a specialist, the following information is helpful in understanding the need of the referral and your healthcare management. The referral process serves as a way for your Primary Care Physician (PCP) and your specialist to communicate with each other. When a referral is issued to see a specialist, your PCP will tell the specialist the reasons for the referral and the goals for your visit. In other words, your PCP will help coordinate your visit and the referral helps to make sure you receive the proper care when you see the specialist.

If your PCP determines you need to see a specialist or receive specialized services, he or she will issue a referral. In the referral process, your PCP gives approval for you to see a specialist and then tells the specialist and the plan of this approval. This is typically done online, so you likely will not receive a paper referral.

Whose responsibility is it to obtain the referral under my the plan?

Your PCP is responsible for issuing the referral. However, you are responsible for making sure this is done before you see a specialist. We recommend you become familiar with and understand your PCP’s specific referral procedures. Every office does this a bit differently, but most offices have a referral coordinator or other staff member dedicated to helping you through the process.

When you go through the process, make sure you follow the steps listed below (as well as any other steps your office may require):

  1. Make sure you know which specialist your PCP is sending you to, as well as the reason for the referral.
  2. Make sure the specialist is an in-network provider.
  3. Make sure your appointment is scheduled within the time frame covered by the referral, and that you know how many visits the referral covers.
  4. Make sure you contact the specialist’s office at least one business day before your appointment to be sure your referral was received and processed.

If your referral covers only one visit but the specialist says you need to come back for another office visit, the specialist should contact your PCP to extend the referral.

Prior Authorizations

In the prior authorization process, your physician or other health care provider gets approval from the plan to provide you with coverage for certain services, such as specific procedures, medications, or durable medical equipment.

Covered services that need approval in advance are marked in the Medical Benefits Chart of your Evidence of Coverage by an asterisk (*). Refer to the plan formulary for a list of Part D drugs requiring prior authorization.

How is a prior authorization different from a referral?

If your physician determines you need a service that requires a prior authorization, such as durable medical equipment or a transplant, your physician will get approval for coverage from the plan before this service is provided to you. If your physician determines you need to see another medical professional for specialized services, your physician will give you a referral, which is an approval from your physician to see this specialist. Both the plan and the specialist are told of your physician’s approval.

Said another way, your physician must get approval from the plan before giving you a service that requires a prior authorization. Your physician does not need to get approval from the plan when providing you with a referral to see a specialist, as long as the specialist is a participating (in-network) specialist.

Is a prior authorization needed for emergency care?

No. A prior authorization is never needed for emergency care. In an emergency situation, go to the nearest emergency room or call 911.

Y0027_20-322 - Last updated 01/30/2020