member news
Services that do
not require a referral
D
o you know when you
need a referral from your
Primary Care Provider
(PCP) before getting a service?
What the difference is between
a referral and an authorization?
Are you able to go to a non-
contracted provider? What about
an out-of-area doctor?
It can be confusing to understand
all of the rules of your health plan.
But they are important to follow.
If you don’t follow them, your
services may not be covered. You
may have to pay for them yourself.
Here is information to help you
make sure you are following the
rules of your plan.
Referrals.
If you are assigned to
an Alliance PCP, you
must
have a
referral before you can see another
doctor. There are some exceptions
to this. Please see the box at right
for the exceptions.
A
referral
is when your PCP
thinks you need to see another
doctor. Your PCP lls out a Referral
Consultation Form. A copy goes to
the other doctor and a copy to the
Alliance. e referral is the way the
other doctor knows that your PCP
has approved the visit. It is also
the way we 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 local doctor inside of our service
area. Our service area includes
Santa Cruz, Monterey and Merced
counties. If your PCP refers you
to a doctor outside of our service
area, your PCP will need to get
authorization from us in advance.
is 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.
ere are other times you might
need an authorized referral. If you
are an Alliance Healthy Families,
Healthy Kids, Alliance Care IHSS or
Alliance Care AIM member, you will
need an authorized referral if your
PCP is referring you to a doctor that
is not contracted with the Alliance.
Even if that doctor is inside of our
service area.
Prior authorization.
Some
services, procedures, types of
medication and equipment need to
be approved by the Alliance before
you get them. is is called
prior
authorization
. e provider who
is going to perform the service
must ll out a
request for prior
authorization
. e provider sends
the request to us. We will review the
request and any medical records
the provider sends with it. If the
service, procedure, medication or
equipment is medically necessary
and is a covered bene t, we will
approve the request. We will let the
provider know and then you can get
Confused by referrals
and authorizations?
All Alliance members:
Emergency services
You are covered 24 hours/day,
7 days/week for emergency services.
Alliance Medi-Cal members:
Family planning services
Pregnancy testing and birth control.
Sensitive services
Testing and treatment of sexually
transmitted diseases and
termination of pregnancy. You can
go to any provider who accepts
Alliance Medi-Cal for these services.
Annual well-woman exam,
Pap smear and breast exam
You can go to any OB-GYN provider
who accepts Alliance Medi-Cal for
this service once a year.
All other Alliancemembers:
Annual well-woman exam,
Pap smear and breast exam
You can go to any contracted
OB-GYN provider within our service
area for this service once a year.
the service. If we deny a request,
we will let the provider know. We
will also let you know. You will
be able to le a complaint if you
disagree with our denial.
5
living
healthy
