A referral and a prior authorization are two different approvals, and both can hold up care.
Your plan may need to approve certain care before you get it. You can review the status and details of referrals and prior authorization requests for everyone on your plan.
What each one is.
Referral
Some plans require your primary care doctor to refer you before you see a specialist. Whether you need one depends on the plan type and the service, so check your plan documents before booking. Without a required referral, the visit may be denied or paid at a lower level, so ask the office to confirm first.
Prior Authorization
The plan approves certain services, drugs or tests before you receive them. The provider usually sends the request. Rules vary by plan and by service, and approval is not a guarantee of payment. Check your plan documents or call the number on your ID card to see which services need it.
Notification
Some plans only need to be told about certain services, such as a hospital admission. Notification is usually a lighter requirement than approval, but missing it can still affect how a claim is handled. Ask the provider who will make the call, and confirm it was received.
The provider asks, the plan decides, you check.
The Provider Submits
Your doctor’s office sends the request with the clinical details. Give the office your current insurance card and plan details, and ask when they expect to send the request and how you will hear back. A complete submission up front usually moves things along faster.
The Plan Decides
The carrier reviews the request against its rules and makes a decision. The plan may approve the request, deny it, or ask for more information, and timing can vary with how urgent the service is. Ask the provider’s office how you will be told of the outcome.
You Check the Status
Review the status and details for each family member before the appointment. Plans often show request status online or by phone, so look before the appointment rather than on the day. If nothing has been approved yet, ask the office whether the visit should be rescheduled.
What to do if it is delayed or denied.
Ask the Provider to Resubmit
Missing details are the most common cause of delay. If a request is delayed or returned, call the provider’s office and ask what is missing. Supplying the clinical notes or forms the plan asked for often gets the request moving again without starting over.
Ask for the Decision in Writing
You will need it to appeal. If a request is denied, ask the plan for the written notice that explains the reason and how to appeal. Keep it with your records, and ask your HR contact or benefits adviser if you need help with next steps.
Appeal or Ask for Help
See denied claims and appeals and our claims advocacy work.
What people ask about referrals and prior authorizations.
Is an approval a guarantee of payment?
No. It shows the service was approved, but coverage and eligibility rules still apply.
Do emergencies need approval?
Emergency care is generally not subject to prior authorization.
Do prescriptions need prior authorization?
Some drugs do. That sits on the pharmacy side. See pharmacy benefit consulting.
Why would a plan require a referral?
Plans use referrals to steer members through a primary care doctor first.
How long does it take?
It varies by plan and service. Urgent requests are handled faster.
Can CFH help?
For the accounts we serve, our team can help escalate with the carrier.
Related reading: Denied claims and appeals · Claims advocacy · Pharmacy benefit consulting · Reading your plan documents
Related reading: Explanation of benefits (EOB)
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