A prior authorization is obtaining permission from the patient's insurance company for certain procedures, services or medications. For example, a prior authorization may be required to have an MRI or Surgery.
A referral is a document from a provider sending a patient to another provider. For example, a family practice provider to an orthopedist. Referrals are sometimes required by insurance companies.
Physician to Physician Referral
This type of referral is a document from one physician sent to another physician. Insurance has not been involved in the process.
Insurance Approved Referral
A physician to physician referral that has been reviewed and approved by the patient's insurance. Some insurances require insurance approval prior to the patient being seen by the physician they are being referred.
Please note that referrals can be required in conjunction with an authorization in order for the insurance to reimburse for procedures or services.
Questions to ask Insurance Company
- Is my Everett Clinic provider included in my insurance plan’s provider network?
- Is this a covered benefit? Many procedures that do not require an authorization or referral but may not be a covered benefit.
- What hospitals are included in my provider network?
- What are my co-pays for primary care visits? What are my co-pays for specialist visits?
- What preventive care services or well visits are covered on my plan?
- Do I need a referral from my primary care doctor before seeing a specialist?
- Do I need prior authorization from the insurance company before scheduling any diagnostic tests (CT scans, MRI tests, etc)?
- Do I need prior authorization from the insurance company for any medications that are prescribed for me?
- Do I need prior authorization from the insurance company before scheduling any procedures including surgery?