How to know if you need a referral and how to get one

Q. Do I need a referral? How do I get one?

If you’ve been seeing your primary care provider (PCP) for a while, chances are you have a bond based on trust. That’s a good thing. After all, your PCP is all about your good health. But what if you need to see someone else? A specialist who can treat you for a specific illness or condition?

When you are covered under an HMO plan and need to be treated by a specialist, your PCP needs to submit a referral request. The request is reviewed to make sure it meets your plan’s approval requirements. When the referral is approved, we notify your PCP and they’ll let you know.

We know referrals can seem confusing, so we’ve put together a guide to help you understand how they work.

PPO plans do not require a referral before treatment — even if you go to a specialist. You may want to contact the doctor’s office ahead of time to see if they have any special requirements. Some specialists may want you to see your primary doctor before coming to see them.

Though PPO plans don’t require referrals, some services may need a prior authorization before your claim can be processed or services are provided.

If you’re planning an inpatient hospital stay, it will probably require prior authorization before you are admitted. Many plans also require that we be notified within a certain timeframe after you are admitted to the hospital for an emergency stay. Your doctor can contact us to request  prior authorization for you.

Some outpatient procedures also require prior authorization. There isn’t a complete list of all the services that require prior authorization since they vary from plan to plan. You or your doctor can always contact us directly to learn about your plan’s requirements for any procedure.

If your service does need a prior authorization, your doctor will submit a letter explaining reasons for the recommended service. Any documents that support the request (medical records, test results) should also be sent. Once we receive the request, it is reviewed by a member of our medical team. When a decision is made, your doctor will be notified.

We understand the referral and prior authorization processes can seem daunting. That’s why our customer service team is here to answer any question you or your doctor may have as you plan your health care.

Contact our customer service department at the number on your identification card. You can also reach us through private message here on Connect, or via  the Message Center on Blue Access for MembersSM. We’re happy to verify information for your doctor.

Next time you talk with your doctor about your health care plan, make sure you discuss any steps you need to take to verify your insurance coverage.