Referral and a Prior Authorization

Referrals and Prior Authorizations

It is important to understand the difference between a Referral and a Prior Authorization, and how and when to obtain each one.

A REFERRAL is a Practitioner's "Order" or a Member Request that facilitates a Member to see another Practitioner (example, a Specialist) for a consultation or a health care service that the referring Practitioner believes is necessary but is not prepared or qualified to provide. A Referral Order may be submitted by your Practitioner electronically, by telephone, or in writing by fax or mail. A Member can request a Referral by either calling his/her Primary Care Physician or calling Member Services.

Direct Access Providers do not require the Member to obtain a Referral Order. Members that have the Triple Option Rider or Point of Service Rider do not need a Referral Order to see a specialty practitioner unless requesting consideration for the service at the lowest FHCP HMO Cost Share.

PRIOR AUTHORIZATION is a "process" of reviewing a Practitioner Referral Order for certain medical, surgical or Behavioral Health Services to ensure the medical necessity and appropriateness of the requested care prior to the health care service being rendered to the Member. The review process also includes a determination of whether the health care service being requested is a covered benefit under the Member's benefit plan. If the requested service is approved, the service is covered under the benefits defined in the Member’s plan. Members can view their plan and benefit information at any time in the FHCP Member Portal at www.fhcp.com. If the requested service is not authorized, the Member and the Practitioner are notified in writing with the specific reasons for the denial, along with their Appeal Rights.

DIRECT ACCESS Health Care Services are health care services that do not require a Member to obtain a Referral Order. Direct Access Providers may be identified in the FHCP Provider Directory on www.fhcp.com. Members may call Direct Access Providers to schedule their appointments and care without obtaining a Referral Order. Examples of Direct Access Services include: Acute Low Back/Neck Pain Program, Chiropractic Services, Colonoscopy Screenings, Dermatology Services, Gynecology Services, Hearing Aid Services, Hospice (for Medicare members; all Non-Medicare Members require Prior Authorization), Obstetrical Services, Optometry Services, Orthopedic Sport Medicine, Pelvic Health Program, Podiatry Services, Smoking Cessation Program and Weight Management Program.

The following health care services are examples of services that can be completed with a Referral Order from your Practitioner and do not require a Prior Authorization.

• Services provided by FHCP contracted Allergists, Behavioral Health Providers, General Surgeons, Hematologists/Oncologists, Rheumatologists, Orthopedics, Pain Management Providers, Outpatient Rehabilitation Providers including Physical, Occupational and Speech Therapists and Sleep Studies.
• Durable Medical Equipment, such as, canes, mastectomy bras, oxygen, walkers and wheelchairs
• Dialysis

The following health services are examples of services that require a Prior Authorization.

• All inpatient services
• All non-participating providers or facilities in or out of FHCP's Service Area
• Braces, Orthotics, Prosthetics
• Breast MRI's
• Cardiac Rehabilitation
• Chemo-Therapy Treatment (Non-Medicare Members)
• Clinical Trials
• Hyperbaric Oxygen Therapy
• Lymphedema Therapy
• Organ and Bone Marrow Transplants
• Pediatric Subspecialties
• PET Scans
• Pulmonary Rehabilitation
• Radiation Therapy
• Referrals to an Oral Surgeon and Oral Surgery
• Referrals to a Plastic Surgeon or Plastic Surgery
• Requests for Second and Third Opinions
• Surgeries/Procedures that are Inpatient, 23-hour Observation, or Outpatient status
• Tertiary Care – Highly specialized consultative care that has personnel & facilities for advanced medical investigation and treatment
• Varicose Vein evaluations and treatment
• Vestibular Rehabilitation
• Wound Vacs
• Certain Medications as identified on the FHCP Formulary, or FHCP Policy as requiring Prior Authorization
• Services that may be investigative or outside the realm of accepted mainstream medical care

For more detailed information, Members can refer to their Certificate of Coverage/Evidence of Coverage and/or Summary of Benefits Coverage document located in the FHCP Member Portal at www.fhcp.com