Prior authorization and referrals

Prior authorization

Prior authorization is a plan process in which certain services, medications, or procedures may need approval before coverage is confirmed under plan rules. Approval is not the same as a guarantee of final payment.

Referral

A referral is commonly a direction from one clinician to another service or specialist and may be required by some plan types or practices.

Before scheduling

• Ask whether authorization is required for the exact service and location
• Ask who is responsible for submitting it
• Confirm whether it has been approved before the date of service
• Keep the authorization/reference number when available
• Check expiration dates, visit limits, and location/provider restrictions
• Confirm whether a separate referral is also required

If something is denied

Customers should obtain the stated reason, review plan instructions, and ask the insurer or provider what review, correction, or appeal paths are available.