Referrals and Preauthorization
Is a referral needed to see a specialist?
Anthem recently announced an "open access" policy for its Colorado HMO and Point-of-Service (POS) plan members - which means most members may visit any in-network physician specialist without a referral from their primary care physician (PCP) simply by scheduling an appointment for their visit. Child health Plan Plus (CHP+) members still must obtain a referral from their PCP to see a specialist.
HMO members may select physician specialists from our extensive provider network
of health care professionals. However, for the best possible coordination of overall care and for referral guidance, we encourage members to talk to their PCP.
POS and PPO members may visit out-of-network physician specialists without a referral although such visits may result in higher out-of-pocket costs. To receive the highest level of benefits, we encourage members to choose a specialist who participates in our provider network
What a referral includes
. A referral typically includes the office visit and any routine lab work or in-office x-rays that may be performed. When other services or procedures occur during an office visit (such as medication injections or minor skin surgery), preauthorization
may be required.
Coverage for services is governed by the benefits and exclusions listed in your certificate and Health Plan Description Form. You may contact Customer Service at the number on the back of your health plan ID card to determine if a visit to a physician specialist requires a referral or if procedures performed during the visit require preauthorization.
What does "preauthorization" mean?
Preauthorization, sometimes referred to as "pre-certification," is the process used to confirm if a proposed service or procedure is medically necessary. Whenever possible, preauthorization should occur before treatment is received.
The physician who schedules an admission or orders the procedure or service is responsible for obtaining preauthorization. Providers should contact the Provider Authorization number on the back of the health plan ID card to confirm if preauthorization is required.
You may also contact Customer Service at the number on the back of your health plan ID card to determine if a proposed test, equipment, service, or procedure requires preauthorization.
It is important to know if your provider has obtained preauthorization, particularly when visiting an out-of-network provider who may or may not be familiar with Anthem's policies and requirements.
What services or procedures require preauthorization?
Please refer to your certificate and Health Plan Description Form for details about covered benefits, copayments, coinsurance, deductibles and exclusions. Many of the services you may receive require preauthorization, even if the physician office visit itself does not require a referral.
The physician who schedules an admission or orders the procedure or service is responsible for obtaining preauthorization. In-network providers will know how to contact Anthem at the Provider Authorization number on the back of your health plan ID card for benefit coverage information and to obtain preauthorization for the care you may be scheduled to receive.
Out-of-network providers may not always know Anthem's specific preauthorization requirements. We recommend that you confirm with your out-of-network provider(s) that preauthorization (or "pre-certification"), if required, has been obtained. Typically, services requiring preauthorization include:
| Overnight stays at a facility, such as a hospital or rehabilitation facility, or continued stays past the number of days authorized.|
| Emergency Admissions. HMO members must notify their health plan within one business day, if reasonably possible, after being admitted to a hospital.|
| Surgical procedures, radiology tests, and occupational, speech and physical therapy visits.|
| Behavioral health (mental health) care and alcohol/chemical dependency rehabilitation services. You or your physician must contact Anthem Behavioral Health toll free at 800-424-4012 to obtain preauthorization or otherwise coordinate these services.|
Locate your plan below to view a partial listing of preauthorization requirements. Preauthorization requirements are subject to change at any time and without notice. We therefore encourage you to contact Customer Service at the number on the back of your health plan ID card to determine if a particular test, equipment, service or procedure requires preauthorization before receiving services or treatment.
When do I need to obtain preauthorization?
When and in-network provider orders a service or procedure, that provider is responsible for obtaining preauthorization.
When an out-of-network provider orders a service or procedure, you must confirm with that provider that preauthorization has been obtained and/or call Customer Service to determine if preauthorization is required. This is especially important because out-of-network providers may not be completely familiar with Anthem policies.
Receiving treatment without obtaining preauthorization may result in higher out-of-pocket costs for you or the denial of benefits. When preauthorization is obtained, coverage is provided up to your health plan's maximum benefit allowance. Benefits are not provided when:
| preauthorization is not obtained; or|
| preauthorization is requested, but services are determined to be not medically necessary.|
View a list of preauthorization requirements
for specific services and procedures. You may also contact Customer Service at the number on the back of your health plan ID card to determine if a proposed test, equipment, service or procedure requires preauthorization.
What if my health plan does not grant preauthorization for a service?
The preauthorization requirements
chart lists services and procedures most often asked about. Preauthorization requirements are subject to change at any time and without notice. Contact Customer Service at the number on the back of your health plan ID card to determine if a proposed test, equipment, services or procedure requires preauthorization.
If preauthorization for a particular service or treatment is denied, you may be held financially responsible for the expense of the test, equipment, service or procedure. Please refer to your certificate and Health Plan Description Form for details about benefits and exclusions.
You or your representative may appeal the health plan's preauthorization decision by following the procedure outlined in Complaints and Appeals. If you or your provider sought approval from us and the request for benefits was denied, you or your provider may request that we reconsider our decision if you believe we did not have all of the necessary information at the time of the decision.