Central California Alliance for Health | Living Healthy | December 2019

HEALTHY 2 Confused by referrals and authorizations? There are many terms that are used in health care, and sometimes it can be confusing to understand them all. We want to make sure you know how to get services that are covered by your plan, so here is some information that should help. Referral If you are assigned to an Alliance primary care provider, 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. If your primary care provider thinks you need to see another doctor, they will fill out what is called a Referral Consultation Form. Your primary care provider 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 primary care provider has approved the visit. If we don’t have a referral, we will not pay the claim from the other doctor. Authorized referral In most cases, your primary care provider will refer you to a doctor in our service area. Our service area includes Santa Cruz, Monterey and Merced counties. If your primary care provider refers you to a doctor out of our service area, he or she will need to get approval from us in advance. This is called an authorized referral. It is called this because we have to authorize (approve) the referral before you can see the other doctor. If you are an Alliance In-Home Supportive Services (IHSS) member, you will also need an authorized referral if your primary care provider is referring you to a doctor that is not contracted with the Alliance—even if the doctor is in our service area. Alliance members who are enrolled in the California Children’s Services (CCS) Program will also need an authorized referral for specialty care. 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 send us a request for prior authorization, letting us know what you need and the reason why. The provider can send it electronically or by fax or 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 decision. More information For a complete list of services that do not require a referral, see your Evidence of Coverage or Member Handbook. DRUG NAME USED FOR ACTION Tudorza Pressair Stiolto Respimat COPD Added Gardasil 9 (HPV immunization)—expanded coverage to include males and females ages 27 to 45 (now covers ages 9 to 45) Human papillomavirus (HPV) vaccine Added Symbicort—added to formulary for ages under 12 Asthma and COPD Added Sodium chloride 3%, 3.5%, 7% (hypertonic saline) Cystic fibrosis Added Formulary changes