Continuing to Understand Your Health Care – Referrals vs. Authorizations: Why Should I Care?
HealthCare 101: Referrals vs. Authorizations
Why Should I Care?
In today’s healthcare environment, there is a lot of talk about making sure you get a referral or an authorization for your services. If you call to inquire about recommended treatment, questions about “referrals” and “authorizations” may come up. Each health insurance company may have different definitions and circumstances when a referral or an authorization may be needed. It can be very confusing.
Simple terms for referrals
In the simplest of terms, a referral is the process of sending a patient to another provider or location for a health care service or consultation that the referring provider believes is necessary. The referring provider may not be prepared or qualified to provide the service needed. In most cases, your primary care provider may be the person writing and sending the referral for a medical concern they are not able or qualified to do OR just for a consultation. In addition, some health care insurance companies may require that you have a referral for services, outpatient procedures, therapies, medical supplies and laboratory tests. If a referral is not done, it could result in failure to get your claim paid.
Authorizations are more complicated
Authorizations are a bit more complicated and require a lot more information from the health care provider asking for it. An authorization is the process of reviewing specific medical services to ensure that the services are medically necessary or appropriate for care based on your medical situation. Authorizations should be done prior to the service being rendered or performed. In some circumstances, authorizations may be dependent on whether you have benefits for a specific service, regardless if the service is medically necessary.
It’s important to know your insurance coverage
A good understanding of your health insurance company’s referral and authorization requirements is important to ensure that services you receive are covered under your health insurance benefit. You should never assume that your health care provider knows the referral and authorization requirements for your plan. Health insurance companies may have many different benefits and requirements, and your health care provider may see hundreds of patients with different health insurance plans every year. How confusing for everyone!
To find out whether you need a referral or an authorization, contact your health insurance company. Ask specifically about your referral and authorization requirements. Not knowing could result in services not being covered or you having financial responsibility for services that should have been covered.
