Referral vs. Prior Authorization
Referral is the process of sending a patient to another practitioner (ex. specialist) for consultation or a health care service that the referring source believes is necessary but is not prepared or qualified to provide. Your primary care physician will refer you to a participating specialist or a health care service provider if he or she cannot personally provide the care you need. Many referrals do not require an authorization number.
Authorization, also known as precertification, is a process of reviewing certain medical, surgical or behavioral health services to ensure medical necessity and appropriateness of care prior to services being rendered. The review also includes a determination of whether the service being requested is a covered benefit under your benefit plan. Authorizations are only required for certain services. Your physician will submit authorization/precertification requests electronically, by telephone, or in writing by fax or mail.
What to do next?
If the study your child will be receiving requires authorization, please contact the ordering provider to provide appointment details (appointment date/time) in order for the authorization process to begin. Unless, your insurance plan is primary care driven, in which, please contact the primary doctor to request authorization.
Please click on the desired health plan below to verify if prior authorization is required through your health plan for the most common outpatient diagnostic services. Any services not listed on the link, please contact the Authorization Unit at 786-624-3022 for more information.
*Please note that the information listed is general and that each plan group may have distinctive requirements that do not fall within these guidelines. For specific requirements, please contact your health plan directly.