Confused About Referrals and Prior Authorization? You’re Not Alone

We have 24/7 entertainment, our packages show up a day or two after ordering them and we can access any information we want virtually anytime we want. Why should health care be any different?

Well, the short answer is: it’s complicated. We have certain checkpoints in place to make sure you’re safe and your care is covered. These checkpoints, like referrals and prior authorization, can seem like barriers at times. In reality, they’re in place to ensure you get the best care and that you’re covered for that care.

Before we start, let’s clear up some of the terminology. You may have heard someone use the term referral when they really meant prior authorization and vice versa. It’s important to remember that they are, in fact, different. Here’s a breakdown so you’ll understand how they work before you find yourself needing either one.

Referrals

Let’s say you frequently get sinus infections and want to see an ear, nose and throat doctor. You’re free to make the appointment because HAP doesn’t require referrals to see specialists for initial consultations. Sounds great, right?

As with all great things in life, there’s a catch. That specialist you want to see may require a referral from your primary care physician, or PCP. This isn’t a HAP requirement and it varies by specialist.

Here’s why:

Some specialists are booked months in advance. They want to be sure you truly need specialty care and that you’re coming to the right place for that care. I know I’d hate to wait to see someone only to find out I don’t actually need their services or they don’t provide the treatments I need.

If your chosen specialist does ask for a referral, they should notify your PCP who will take care of it for you. This is known as a paperless referral process that’s handled between your PCP and the specialist you want to see.

Pro-tip: To avoid any confusion and make the process seamless:

• Give all of your plan information to the specialist’s office when making the appointment so they can confirm your specific HAP plan is accepted. Some specialists may not accept all HAP plans.
• Call the specialist’s office before your visit to check the status of your referral. That way you can be sure you’ll be seen when you show up for your appointment.

Prior authorization

Some procedures, services and medications require approval from HAP before you get them and before we’ll cover them. This is called prior authorization.

We may also require prior authorization before you get care with out-of-network providers. Basically, we just want to make sure you’re on the right track and that the procedure, service or medication is medically necessary.

Generally, we’re talking about more complex services. This can include scheduled, non-life-threatening, or “elective,” surgeries and hospital admissions, imaging like a CT scan or MRI, some behavioral health or chemical dependency services, outpatient services and even prescription drugs.

For a list of common services that require prior authorization, log in at hap.org. In the right-hand list, click “Member Resources” then “Member Prior Authorization List.” The list is just meant as a reference point. If you need more information about a specific treatment or service, call Customer Service.

A good analogy for prior authorization is car insurance. If you were in an accident, you wouldn’t just get your car repaired and then talk to your agent about setting up a claim. You’d give them a call and they’d send someone out to check out the damage and let you know what’s covered. They’d also, depending on your coverage, let you know where the vehicle could be fixed.

If you don’t get prior authorization, you could end up paying more. You could also pay for a procedure or medication you don’t need. And, that same procedure or medication may not be covered by your plan at all.

Nothing is more frustrating or upsetting than paying for a treatment or service you don’t need. Especially if it’s not covered.

I experienced it firsthand with another health plan and health system. My wife and I paid thousands of dollars for things we didn’t need because there was nothing in place like HAP’s prior authorization system. Had our health plan asked us to check with them first, they may have been able to intervene and save us a lot of time and money.

How prior authorization requests work

Your doctor will fill out a prior authorization form and submit it to HAP on your behalf. Then, both you and your doctor will get a notice of approval or denial from HAP in the mail within 14 days. For medications, the information requested on the form is specific to your condition and may include information about prior treatment or medications you’ve already tried.

If your request is denied, you have the right to know why. You can talk to your doctor or call Customer Service for more information.

At the end of the day, we just want what’s best for you as a member. Health care isn’t on-demand quite yet, but we’re doing what we can to make it as easy as possible to get the care you need, when and where you need it. I hope I’ve helped clear up any confusion around our referrals and prior authorization process.