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Prior Authorizations vs Referrals

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People often wonder if their Medicare plan requires “prior approval” for health services they may need to obtain.  Almost always, what they mean to ask is “Does my Medicare plan require referrals?”

A referral is an order from your Primary Care Doctor (PCP) to see a specialist or receive certain medical services from some providers. Your PCP helps make the decision about whether specialist services are necessary for you before authorizing the referral.

Prior authorization is approval from the health plan before you get a medical service such as an MRI, or lab work.  Prior authorizations can also be required, along with a prescription from a doctor, to purchase certain drugs from a pharmacy.

All medical plans will require prior authorization for certain medical services.  For example, you can’t just walk into a radiology office and request an MRI!  Obtaining an

MRI will require a prior authorization from a medical provider.

Referrals may or may not be required from your insurance company, depending upon the type of Medicare plan that you have.

Medicare Supplements, also known as MediGap plans, do NOT require referrals to see specialists.  Popular Medicare Supplements include Plan F, Plan G or Plan N, although there are other plans to choose from as well.

Medicare Advantage plans may or may not require referrals, depending upon the type of Medicare Advantage plan a person is enrolled in.  Enrollment in an HMO (Health Maintenance Organization) Medicare Advantage plan will most often, but not always, require referrals to see specialists.

Plans with Networks

Regardless of whether or not a referral is required, HMO plans generally require enrolled members to obtain all of their care from providers who are in the plan’s network.

Enrollment in a PPO (Preferred Provider Organization) Medicare Advantage plan typically does NOT require referrals to see specialists.  PPO plans allow for enrolled members to receive medical services from providers out of the plan’s network, but the cost to visit an out-of-network provider is typically more expensive than if the provider was part of the plans’ network.

In summary, prior authorization is approved by your plan before a procedure is done or prescription is filled. Referrals are provided by your Primary Care Physician to see another physician or specialist.

If you have questions about prior authorizations, physician referrals, or any other Medicare questions, please contact your Member Agent.

Don’t have a Member Agent to help you yet?   Click here to use our Agent Finder.

Member Agents are here to help you and their educational services are always free of charge.

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