Referrals and Authorizations
Many managed care plans require PCP referrals and/or plan authorizations in order for services to be covered. They help to reduce costs and encourage appropriate use of health care services to ensure that patients receive quality care and continuity in their treatment. These plan requirements can be confusing at times. Below is a brief description of the difference between a PCP referral and a plan authorization.
When a patient has health coverage through an Health Maintenance Organization (HMO) they are generally required to select a Primary Care Physician (PCP) who is responsible for providing and coordinating their medical care. For most HMOs, a referral is required for visits to specialists. The referral serves as a mechanism for coordinating the patient's care and communicating with the specialty care provider. If your plan requires a referral, your primary care physician (PCP) must provide the referral prior to services being rendered. If you arrive for services without a referral in place, you may be asked to sign a waiver that holds you financially responsible for the services you receive.
Plan authorization, unlike PCP referrals, is often required by all managed care plans. The PCP, specialist, and/or provider of service must call the health plan for pre-approval for specific services. Plan authorization requirements vary by each health plan and are generally required for procedures such as outpatient surgery or expensive imaging procedures, such as a MRI. If a plan authorization is required, UMHS clinic staff will contact your managed care plan to receive permission from the plan prior to providing the service. If you have questions about whether a service will be authorized, please call your health plan.
PCP referral and plan authorization requirements vary depending on the product type.Click here for referral and authorization highlights by product type.
PCP referral
A PCP referral serves as a mechanism for coordinating a patient's care and communicating with the specialty care provider.
If your health plan requires a referral, your primary care physician (PCP) completes and forwards a referral form to the
health plan and specialty provider authorizing the member's care. On the referral form the PCP describes the specialty
services being ordered. If additional treatment is recommended or needed per the specialty area, another referral form
will need to be issued. A PCP referral is a common requirement with Health Maintenance Organizations (HMO) and Point of
Service (POS) type plans.
Plan Authorization
A formal process requiring a provider to obtain prior approval from the patient's health plan before providing a
particular service or procedure. It is a process in which the plan determines whether the service is medically appropriate
prior to the provision of care. Plan authorization (sometimes called authorization, prior authorization,
pre-certification, or certification) is required for any medical service that requires clinical review such as inpatient
admissions, certain outpatient surgeries, diagnostics, and therapies. Unlike PCP referrals which are required by only
certain products, plan authorization is required by all managed care plans including HMOs, PPOs, and POS products.
