Central California Alliance for Health | Living Healthy | December 2017

member news D o you know when you need a referral from your Primary Care Provider (PCP) before getting a service? What is the difference between a referral and an authorization? Are you able to go to a non-contracted provider? What about an out-of-area doctor? The rules of your health plan can be confusing. But if you don’t follow them, your services may not be covered. Here is information to help you follow the rules of your plan. Referrals. If you are assigned to an Alliance PCP, you must have a referral to see another doctor. There are some exceptions to this. See your Evidence of Coverage or Member Handbook for a complete list.   MORE INFORMATION. For a complete list of services that do not require a referral, see your Evidence of Coverage or Member Handbook. Confused by referrals and authorizations? If your PCP thinks you need to see another doctor, he or she will fill out a Referral Consultation Form. Your PCP sends a copy to the doctor you are being referred to and a copy to the Alliance. The referral is how the other doctor and the Alliance know your PCP has approved the visit. If we don’t have a referral, we will not pay the claim from the other doctor. Authorized referrals. In most cases, your PCP will refer you to a doctor in our service area. Our service area includes Santa Cruz, Monterey and Merced counties. If your PCP refers you to a doctor out of our service area, he or she will need to get approval (also called authorization) from us in advance. This is called an authorized referral . It is called this because we have to authorize, or approve, the referral before you can see the other doctor. If you are an IHSS member, you will need an authorized referral if your PCP is referring you to a doctor that is not contracted with the Alliance—even one in our service area. Prior authorization. The Alliance has to approve some services, procedures, medications and equipment before you get them. This is called prior authorization . The provider who is going to perform the service must fill out a request for prior authorization . The provider sends it to us online, by fax or by mail. We will review the request and any medical records the provider sends. If the service, procedure, medication or equipment is medically necessary and a covered benefit, we will approve the request. We will let the provider know, and then you can get the service. If we deny a request, we will let you and the provider know. You will be able to file an appeal if you disagree with our denial. 2 living healthy