November 10, 2022
The health insurance space is full of highly specific terminology and can be confusing to plan members. “Referral” and “prior authorization” are commonly used terms that are essential for the member to understand.
A referral is a written order from a primary care provider (PCP) for the client to see a specialist outside of the medical group they’ve selected for care. Here are a few things to know about referrals:
- If the PCP refers your client to see a specialist that is part of their medical group, they don’t need to send anything to Premera.
- If the PCP wants your client to see a specialist not in their medical group (but they are in our MA network), the PCP does need to let Premera know about the referral. Routine referrals process within 14 days. Urgent referrals will be processed within 72 hours.
- Emergency care is always covered without a referral. We advise members to try and stay in network for care whenever possible.
- Premera Medicare Advantage plans don’t cover non-emergency services received from an out-of-network provider.
- Your client doesn’t need a referral from a PCP if they see an in-network provider for the following services:
A prior authorization is a request from a PCP or specialist to perform certain services or prescribe certain medications. Some healthcare services and prescription drugs must be approved by Premera before they are covered under your client’s plan. Prior authorizations help ensure that your client is getting the right care, at the right place, and at the right time. Here are a few things to know about prior authorizations:
- The PCP or the specialist sends the prior authorization to Premera before ordering a test, certain medications, or surgery.
- For general requests, Premera will let the provider know within 14 days of receiving the request if it’s approved or denied.
- For urgent requests, Premera will let the provider know within 72 hours of receiving the request.
- Premera will let your client and the doctor know why a request is denied.
- If the request is denied, your client and their doctor can choose another treatment option or provide us with more information so we can review the request again. Many times, requests are denied because the provider didn’t submit all the necessary information.
- If the service is denied, your client and their doctor can appeal the decision.
- If your client receives the service or the drug without prior authorization, your client will be responsible for the costs.