A referral to an authorization is a slippery slope. First let’s define each term.
Referral is your primary doctor saying you need to see this specialist. They sometimes give you a piece of paper or they will call the specialist for you.
Authorization is when you or your doctor calls your insurance company and gets permission to perform the requested treatment.
How do you know which one you need? Read your plan documents and they should tell you; however, this is where that slippery slope comes in. It’s all down to interpretation.
The silent factor:
Sometimes your benefit will not say either way. It just gives you your benefit and you are left wondering if you need an authorization. Tip–call your insurance company and ask.
The two places dilemma:
Most people look for the grid like pages that state what the services is, what their co-pay is and what their insurance will cover. Often this benefit will not mention prior authorization, but somewhere in the pages before or after that grid will be an explanation of what needs authorization and what doesn’t. So don’t just rely on the grid.
The specialist loophole:
So you have read your benefits and it just says, same as medical or treat like a physician visit so you figure you are safe and you do not need an authorization or referral. Wrong. Depending on your doctor type you will need to see if referrals or authorizations are needed to see a specialist. Now what you would think of as a specialist compared to what your insurance company thinks is a specialist is probably going to be very different. So read carefully, and a safe assumption is that if it’s not a general doctor who you would go to for the flu, then call and get an authorization from your insurance company, or at least call and ask.
The It said referral but I was denied for no authorization situation:
Here is the core issue here. Your insurance claims department does not know what they are doing or your doctor’s biller does not know what they are doing. What happens is that the claims department will deny because they use referral and authorization interchangeably even though they are two different things. The other issue is that your specialist will bill and not send a copy of your primary doctor’s referral with his or her bills. Therefore you insurance company does not know that the referral exists and denies. The solution is that if your benefit says you need a referral, get one, but then call your insurance company and ask for authorization too. If they say it’s not needed then you at least tried.
Whenever you talk to your insurance company have a notepad and pen handy.
Record the following for any conversation that you have:
The date and time.
The phone number you called.
The first name, last initial and location of the person you are talking to . This could be a state in the U.S. or a city in a different country. Not everyone will want to give you this information. If they refuse, ask for their manager.