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

Q. I’m having a service done, do I need a referral? How do I get one?

When you are covered under an HMO plan and need to have a service performed by someone other than your primary care provider (PCP) your provider will need to submit a referral request. This request will be reviewed under your plan to make sure it meets the approval requirements. When the referral is approved we’ll notify your PCP and they’ll let you know. We know referrals can get confusing so we’ve put together a helpful guide to this process.

PPO plans do not require a referral before having a service performed; even if you’re going to a specialist. However, you may wish to contact the doctor’s office who will be performing your service to see if they have any special requirements; for example, 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 precertification or prior authorization before your claim can be processed or before services are rendered.

If you’re planning an inpatient hospital stay those typically do require a precertification before you are admitted. Additionally, many plans do require we be notified within a certain timeframe after hospital admission for emergency stays. Your doctor can contact our precertification department for you to complete this process.

There are some outpatient procedures, for example some diagnostic radiology procedures, which may require your doctor to submit a request for approval or prior authorization . While there isn’t a comprehensive list available of all the services that require authorization, as this can vary from plan to plan, you or your doctor can contact us directly to check your plan’s requirements for any procedure you need.

If your service does need a prior authorization your doctor can submit a letter explaining why they are recommending the service along with any documents that support this request, such as medical records or test results. Once we receive this request it will be reviewed by a member of our medical team. When a decision is made your doctor will be notified and you can work together to take the next steps for your care.

We understand these referral, precertification, and prior authorization processes can be hard to understand. That’s why our customer service team is here to help answer any question you, or your doctor, may have as you plan out your health care needs.

You can contact our customer service department at the number on your identification card, through a private message here on Connect, or through the Message Center on Blue Access for Members for information on your plan’s requirements for a service. Our provider services area can also verify this 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.