Understanding Health Insurance Referrals and Prior Authorizations

Some health plans demand referrals or prior permission before you may obtain services from health care providers other than your primary care physician (PCP). A referral is an order from your primary care physician to visit a specialist or obtain specific medical treatments from selected providers. Your primary care physician will assist you in determining if you require expert treatments. Prior authorization is approval from your health plan before you receive a service or fill a prescription. The health plan evaluates medical information from your physicians and determines if the treatment or prescription medicine fits the plan’s medical necessity requirements. When they are necessary, your health plan may not cover any of the expenses of the treatments unless you get a referral or prior permission. So know about licencias y autorizaciones sanitarias

Some health plans, such as Point of Service (POS) plans, need referrals to see specialists. Other types of health plans, such as Health Maintenance Organizations (HMOs) and others, may need prior authorization for certain treatments. If you want specialised treatment, services, or medical equipment, your health plan may require prior permission. This is referred to as prior authorisation. When a service is medically required, a health plan will provide prior permission. Without it, your health plan may not cover any charges. You can ask your physician if you require prior authorisation. Prior authorization is obtained directly from the health plan by some providers.

Things you should know

In an emergency, go to the nearest hospital. Your health plan cannot require prior authorization before you visit the emergency room. Depending on your plan, you may still be required to pay part of the expenses of emergency services. For example, if you haven’t reached your deductible, you may be required to pay a portion of the charges. When it is not an emergency, you can check your health plan’s website or documentation, or call the plan, to see if a treatment you seek requires a referral or prior permission. Check with licencias y autorizaciones sanitarias

So, you may be wondering, why can’t other clinicians or pharmacists obtain prior authorization? Because insurance companies require patient information that only your doctor may have access to. Prior authorizations frequently include test findings, treatment history, and other important information. Adoption of the electronic medical record and enhanced contact among healthcare professionals should only make this process easier and faster. Insurance companies prefer the delay of having to go via a physician for submission. Delays save them money. With each delay or impediment to obtaining permission, more patients abandon the process.