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Understanding Health Insurance Referrals and Prior Authorizations
Some health plans require referrals or prior authorization before you receive services from health care providers other than your primary care provider (PCP). A referral is an order from your PCP to see a specialist or receive certain medical services from some providers. Your PCP helps make the decision about whether specialist services are necessary for you.
Prior authorization is approval from the health plan before you get a service or fill a prescription. The health plan reviews medical records from your providers and decides whether the service or prescription drug meets the plan’s rules for medical necessity.
When they are required, your health plan may not pay any of the costs of the services without a referral or prior authorization.
Some health plans, like Point of Service (POS) plans, require referrals to see specialists. Other types of health plans, including Health Maintenance Organizations (HMOs) and others, may require prior authorization for some services. If you need special treatment, service, or medical equipment, you may need to get approval first from your health plan. This is called prior authorization. A health plan gives prior authorization when a service is medically necessary. Without it, your health plan may not pay any of the costs. You can ask your provider if you need prior authorization. Some providers contact the health plan directly for prior authorization.
THINGS YOU SHOULD KNOW
In an emergency, you should go to the closest hospital. Your health plan can’t require prior authorization before you go to the emergency department. You may still have to pay some of the costs of emergency services depending on your plan. For instance, you may have to pay a co-pay or part of the costs if you haven’t met your deductible.
When it’s not an emergency, you can check your health plan website or documents, or call the plan, to find out if a service you need requires a referral or prior authorization.
TOP THINGS TO REMEMBER
- Contact your health insurance plan for referrals. In some instances, if you don’t get a referral before receiving care, the plan may not pay any of the costs of the services.
- Ask your provider if you need prior authorization for your medical care. Some providers may contact your health plan on your behalf for prior authorization. If prior authorization is required, the plan will likely need medical records from your provider.
- If you go to an emergency department, your health plan can’t require prior authorization before your visit.
About the National Association of Insurance Commissioners
As part of our state-based system of insurance regulation in the United States, the National Association of Insurance Commissioners (NAIC) provides expertise, data, and analysis for insurance commissioners to effectively regulate the industry and protect consumers. The U.S. standard-setting organization is governed by the chief insurance regulators from the 50 states, the District of Columbia and five U.S. territories. Through the NAIC, state insurance regulators establish standards and best practices, conduct peer reviews, and coordinate regulatory oversight. NAIC staff supports these efforts and represents the collective views of state regulators domestically and internationally.