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Hospital stays and some types of procedures and treatments need require a prior authorization. When that’s the case, your doctor sends information to us about recommended care before you receive it.
If prior authorization is required, but not received, you may have to pay a larger part of your treatment costs.
When you schedule an appointment, your doctor’s office will ask you for your health plan information. They use this information to make sure your coverage is active and can be billed for your visit.
Once coverage is confirmed, your doctor or other health care provider will see you. They may do a physical exam and ask you questions about your health concerns. Afterward, your doctor will diagnose you or decide if tests like blood work or X-rays are needed. These tests offer clues about your health issue so you and your doctor can decide on a treatment.
When a course of treatment has been chosen, your doctor may need to share findings with us. The information may include the results of testing or a physical exam. Your doctor will also give us any additional details we need.
This exchange of information is a vital part of prior authorization. It helps ensure you get the right care at the right place. We use the information to answer these questions about the recommended treatment:
Is it needed? The doctor will give us details about your health issue so we have enough information to see if the care meets the “medically necessary” guideline. For example, you may not need an MRI or CT scan if it isn’t needed to make a diagnosis or if they’ve been already been done by another doctor.
Is it covered? Not everything a doctor can do is covered by all health plans.
Is it in your health plan’s provider network? If your doctor sends you to a specialist or hospital that isn’t in your network, you could pay a lot more — or even all — of the charges.
Is it the right level of care? Do you really need to see a specialist or go to an imaging center? Should you be admitted to a hospital, or is treatment available at an outpatient center?
How long will it take? Your doctor’s care plan estimates how long it will take you to get the care you need and be well enough to go home. If either takes longer than expected, your care provider will let us know. so .
Getting the answers to these questions helps us work with the doctor so you enjoy access to the right care. Together, we make sure your care is covered by your health plan.
Your primary care physician (PCP) will write a referral when you need to see a specialist. For HMO plans, a referral is required. Some point-of-service (POS) plans may also require a referral to ensure coverage at the full benefit level.
The referral may be sent directly to the specialist via email or fax. Or you may be provided with a copy to take with you to your visit.
Before you are seen, the specialist’s office will make sure that:
It’s also a good idea to double check with the specialist’s office to make sure these steps were done before your visit. Doing so helps you avoid a trip to the specialist’s office only to be told you can’t be seen.
For health plans other than HMO and POS, a referral usually isn’t needed, but doctors may still give you one or call it in. It’s simply a way for the specialist to have all the important facts about your health issues before your visit.
A referral gives specialists, hospitals and other facilities the information they need to get prior authorization, if needed. It also creates a chain of care so that your doctor stays informed about any findings, treatment plans and hospital admissions.
Not all procedures require pre-service reviews. For a full list of procedures that require pre-service review, check your benefit information by logging in to your Blue Access for MembersSM account. Select the My Coverage tab and click on the prior authorization link under My Coverage Benefits.
Some drugs may need prior authorization. They may not be covered under your plan or may not have been proven effective treating your health issue. The only way your doctor or pharmacist may know is by getting approval first.
Here are some reasons a drug may not be approved:
When reviewing drugs and their use, we consider these things and more. It’s a good idea for you and your doctor to consider your approved drug list when making choices about how to manage your health.
You can check your health plan’s approved drug list before you go see your doctor. It will save time and money when you’re getting prescriptions filled.
If your copay seems high when you get a new prescription filled, ask the pharmacist if the drug is covered by your plan.
Your pharmacist can also check to make sure a new drug isn’t harmful if combined with another drug you are already taking. They may have more information than your doctor about what drugs you are taking and how the drugs work when taken together.
If there is an issue, your pharmacist may:
Prior authorization for drugs is usually handled by the pharmacy. It isn’t required for every drug.
Many times, your prescription can be filled while you wait. If it is a new prescription, a special drug or new on the market, it may take longer. If you need the drug quickly, the pharmacist can ask for an expedited review.
There are hundreds of medications. More are becoming available every day. By using prior authorization, you get a safe drug that works at the lowest cost.
Originally published 12/30/2019; Revised 2021
Blue Cross and Blue Shield of New Mexico, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
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