Understanding Prior Authorization and Referrals
As a health plan member, it is important to understand when you need prior authorization and when you need a referral for services. Here is a simple guide to help you navigate these requirements:
What is Prior Authorization?
Prior authorization is a process where your provider must obtain approval from your health plan before providing certain medical services. This ensures that the service is medically necessary and covered under your plan. In general, prior authorization is requested by your healthcare provider to your health plan.
When Do You Need Prior Authorization?
- Ambulatory surgeries (e.g., surgeries in hospitals or outpatient facilities)
- Specialist visits when there will be more than 4 visits needed
- Elective hospitalizations
- Out-of-network providers
- Specific treatments (e.g., chemotherapy, radiation therapy, dialysis)
- High-cost outpatient procedures (costing over $500)
- Genetic testing
To view the full list of Authorization Codes, please click Services that Require Authorization Codes.
What is a Referral?
A referral is when your primary care physician (PCP) directs you to see a specialist or receive specific services. The referral indicates that the PCP believes a specialist is necessary for some of your care. Your PCP initiates the referral.
When Do You Need a Referral?
- For most specialist visits.
- If you need to see a physician who is not contracted with your insurance plan.
- To access covered services not available from in-network providers.
- For services like occupational therapy, speech therapy, and certain mental health treatments.
Which Services Do Not Need Prior Authorization or Referral?
- Outpatient Mental Health Services: In-network office visits.
- Pregnancy-Related Services: Medically necessary prenatal tests (excluding genetic testing).
- HIV Treatment: Screening, prevention, testing, diagnosis, and treatment.
- Physical Therapy: Initial evaluation and six follow-up sessions in-network.
- Acupuncture Therapy: Up to 18 sessions per year in-network.
- OB/GYN Services: Routine and preventive services including mammograms.
- Annual Flu Vaccine: Self-referred in-network.
Decisions regarding requests for authorization will be made only by licensed physicians or other appropriately licensed medical professionals.
Balance and its participating medical group have certain procedures that will make the authorization decision within the time frame appropriate for your condition, but no later than five business days after receiving all the information (including additional examination and test results) reasonably necessary to make the decision. Decisions about urgent services will be made no later than 72 hours after receipt of the information reasonably necessary to make the decision.
If the Medical Group needs more time to make the decision because it doesn’t have information reasonably necessary to make the decision, or because it has requested consultation by a particular specialist, you and your treating physician will be informed about the additional information, tests, or specialist that are needed, and the date that the Medical Group expects to make a decision. Your treating physician will be informed of the decision within 24 hours after the decision is made by telephone or facsimile. The plan will notify the physician and the Member in writing within two business days of making the determination.
If the Medical Group does not authorize all of the services, you will be sent a written decision and explanation within two business days after the decision is made. The letter will include information about your appeal rights, which are described in the “Grievance and Appeal Process” section of the Combined Evidence of Coverage and Disclosure Form. Any written criteria that the Medical Group uses to make the decision to authorize, modify, delay, or deny the request for authorization will be made available to you upon request. Once Balance authorizes a specific type of treatment by a provider, it shall not rescind or modify the authorization after the provider renders the health care service in good faith.
Questions or Need Help?
Please contact Member Services for questions about Mental Health Benefits, In-Network Provider Access, Claims Processing, and ANY other questions or concerns regarding your Balance membership.
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