Understanding referrals and prior authorization

Understanding referrals and prior authorization

At Aspire Health, we want to make Medicare Advantage and health insurance easier to understand so that our members can get the care that they need. With this in mind, we wanted to explain referrals and prior authorization – what they mean and how they apply to our Medicare Advantage plan members here in Monterey County.

What are referrals in Medicare Advantage?

There are often misconceptions within health maintenance organizations (HMOs), about how to get the care you need. One of the misconceptions about Aspire Health Plan is that you need a referral to see a specialist. A referral is a written order from your doctor for you to see a specialist or get certain medical services. At Aspire Health Plan, we do not require referrals for you to see covered specialists.

Some specialists, however, may require a referral from your primary care physician (PCP). This is to ensure that you are getting the best course of care. You should always check with your PCP before seeing a specialist so they can help coordinate your care.

What is prior authorization in Medicare Advantage?

Medical services requested by your PCP or specialist may require prior authorization from the plan. Prior authorization is a decision by the health plan that a healthcare service, treatment plan, prescription drug, or durable medical equipment is medically necessary and would otherwise be covered by Medicare. Prior authorization is not intended to create “red tape” or barriers. Rather, it gathers the information necessary to support Medicare coverage.

Generally, your PCP or specialist will request any necessary prior authorization from the plan. However, it is your responsibility to ensure that prior authorization has been granted before having any medical service or procedure.

Why does Aspire Health Plan need prior authorization?

The prior authorization process gives Aspire a chance to review how necessary medical treatment or medication may be in treating your condition. Your evidence of coverage (EOC) describes in full all of your covered benefits and any prior authorization requirements that may apply.

What types of medical treatments and medications may need prior authorization?

The following is a list of medical treatments and medications that may need prior authorization:

    • Medications that may be unsafe when combined with other medications
    • Medical treatments that have lower cost, but equally effective, alternatives available
    • Medical treatments and medications that should only be used for certain health conditions
    • Medical treatments and medications that are often misused or abused
    • Drugs often used for cosmetic purposes

How do I get prior authorization?

If your healthcare provider is in-network they will start the prior authorization process. If you don’t use a healthcare provider in your plan’s network, then you are responsible for obtaining the prior authorization.

For Aspire Health Medicare Advantage plan members, we understand you may still have questions. Don’t worry – we’re here to help! If you have any questions about getting the care you need, please contact Member Services at (855) 570-1600.

This article also appears in the summer 2022 issue of the Aspire Advocate quarterly member newsletter. You can access the full issue here along with past issues.


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