Do You Know the Difference Between Prior Authorizations and Referrals?
bcbsm
| 4 min read
Have you ever gone to your primary care physician for treatment and been told a referral* is needed to see a specialist? Or that a prior authorization is needed before medical treatment or services can continue? If so, you may have been confused as to what it all means or what happens next. To start, it’s important to know the difference between the two:
Referrals
As a Blue Care Network member, you’re required to select a primary care physician who manages your care. It’s important to see your primary care physician first when you’re sick or have a non-emergency injury. Sometimes they’ll need to refer you to a specialist. For example, if you have a concern about your skin and your primary care physician thinks you should see a specialist, he or she may refer you to a dermatologist. Your doctor will handle the referral so the specialist can provide care. All you need to do is check that the specialist participates in your plan’s network. If not, then tell your primary care physician that you need a new referral to see an in-network specialist. Look up specialists in your plan’s network using your Blue Cross mobile app or logging in to your account at bcbsm.com. If you have an HMO plan, you can’t see a specialist on your own if your primary care physician doesn’t submit the referral to that doctor. If you see a specialist without your doctor’s referral, or one that doesn’t participate in your plan’s network, then you may be responsible for most or all costs. Check out this flyer to learn more about how referrals work, including how long they last and when you don’t need one.
Prior Authorization
If you have Blue Care Network coverage, there are times when we must approve certain tests, surgeries and other medical services before the treatment or services are provided. This is done so that we can make sure the health services are medically necessary and appropriate for your condition. Getting approval first is important because if the health service isn’t approved, it may cost you more or may not be covered at all. Don’t worry, you’re not responsible for submitting a prior authorization request. That’s something your primary care physician or specialist will handle. That said, even though it’s your doctor’s responsibility, you should always talk to him or her before receiving any health care services to see if our approval is required. Check out this flyer for more information about prior authorizations, including examples of services that require one and what happens if the request is denied.
Where to see your prior authorizations and referrals
Your member account now includes a record of all prior authorizations and referrals for medical services from as far back as June 1, 2017. Use the Blue Cross mobile app or log in at bcbsm.com to:
- Make sure your prior authorization or referral is approved
- See when your prior authorization or referral expires
- Have proof of your approvals, wherever you are
If you’re using the app, you’ll need its latest version. A prompt will ask you to update it when you log in. Once you update and log in:
- Tap My Coverage.
- Select Referrals and Authorizations.
Or choose to go to your member account at bcbsm.com and log in:
- Click the Doctors & Hospitals.
- Select Referrals and Authorizations.
Remember, the process hasn’t changed — your doctor still coordinates your specialty care and submits all the paperwork – but now you have a record of their approvals at your fingertips to help you avoid paying more out-of-pocket for care. Don’t have an account? Sign up for one today at bcbsm.com. For more information, stay tuned for more blogs in our #HMO101 series. For additional health and wellness tips, follow our Facebook page. *Referral requirements work differently in some regions within Michigan and don’t always need to be submitted to Blue Care Network. If you have questions about how referrals work in your area, call the Customer Service number on the back of your Blue Care Network member ID card. Check out these other blogs for more about understanding your medical plan:
