Living Healthy 3 Understanding referrals and authorizations We want to make sure you know how to get services that are covered by your health plan. Below are some important terms used in health care and what they mean. Referral If you are assigned to an Alliance primary care provider (PCP), you must have a referral to see another doctor. ■ If your PCP thinks you need to see another doctor, they will fill out a Referral Consultation Form. ■ If we don’t have a referral, we can’t pay the bill or claim from the other doctor. ■ There are some exceptions. See your Evidence of Coverage or Member Handbook for a complete list. The Member Handbook is found online at www.thealliance.health/memberhandbook. Authorized referral Our service area includes Mariposa, Merced, Monterey, San Benito and Santa Cruz counties. If your PCP refers you to a doctor out of our service area, they will need to get approval from the Alliance ahead of time. This is called an authorized referral. ■ This means that we need to approve the referral before you can see the other doctor. ■ If you are an Alliance In-Home Supportive Services (IHSS) member, you will need an authorized referral if your PCP refers you to a doctor who doesn’t work with the Alliance—even if the doctor is in our service area. ■ Alliance members who are enrolled in the California Children’s Services Program will also need an authorized referral for specialty care. Prior authorization The Alliance must 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 send us a request to let us know what you need and the reason why. ■ If the request is medically necessary and a covered benefit, we will approve it and you can get the service. ■ If we deny a request, you can file an appeal if you disagree with our decision. Prescription drugs If you are a Medi-Cal member, your prescription drugs that are filled at a pharmacy are covered by MediCal Rx and not the Alliance. To find out if a drug is covered, call 800-977-2273 (TTY: Dial 711) or go to www.medi-calrx.dhcs.ca.gov. If you are an IHSS member, pharmacy services are managed by MedImpact. You can view the list of covered drugs at www.thealliance.health/prescriptions. You can request a mailed copy by calling Member Services at 800-700-3874 (TTY: Dial 711). You can also call Member Services if you have questions about if a drug is covered. Drugs given in a doctor’s office or clinic These are considered physician-administered drugs. You can view the list of covered drugs and any changes to the list at www.thealliance.health/prescriptions. If you would like a mailed copy, please call Member Services at 800-700-3874 (TTY: Dial 711).
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