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 areas are Merced, Monterey 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 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 will be able to file an appeal if you disagree with our decision. The Alliance is texting members when it is time to renew their Medi-Cal! You might get a text message from us. LIVING HEALTHY is published for the members and community partners of CENTRAL CALIFORNIA ALLIANCE FOR HEALTH, 1600 Green Hills Road, Suite 101, Scotts Valley, CA 95066, telephone 831-430-5500 or 800-700-3874, ext. 5505, website www.thealliance.health. Information in LIVING HEALTHY comes from a wide range of medical experts. If you have any concerns or questions about specific content that may affect your health, please contact your health care provider. Models may be used in photos and illustrations. 2023 © Coffey Communications, Inc. All rights reserved. Communications Project Specialist Randi Motson Quality and Health Programs Supervisors Desirre Herrera and Ivonne Muñoz www.thealliance.health At every life stage. For any health condition. Trusted, no cost Medi-Cal health care from a local team that understands you. The Alliance—your ally in being your healthiest self.
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