Why do some health plan Customer Service representatives state "All you need is a referral from your PCC and you can go?"
Under managed care HMO, each primary care clinic belongs to a care system. Each care system has their designated network of specialty providers. For you to have your highest benefit, it is a clinic policy to refer to an in network provider whenever possible. Some plans have no benefit without a referral. Please contact your health plan Customer Service for those benefit options.
Referrals are authorizations from your primary physician for specialty services received outside of your primary care clinic, in or out of network. Only the physician has the authority to approve or deny a referral request because of medical necessity, network, etc. Some health plans will not authorize an out of network referral from your physician. Those services would require a PRIOR authorization by the health plan PRIOR to having the service