What are Referrals and Prior Authorizations
Some health plans, mainly Health Maintenance Organizations (HMOs), require a referral before you get care from some providers. A referral is an order from your Primary Care Provider for you to see a specialist or get certain medical services. If you don’t get a referral first, the plan may not pay any of the costs of the services.
Other types of health plans, not just HMOs, may require prior authorization for some services. If you need a special treatment, service, or medical equipment, you may need to get approval first from your health plan. This is called prior authorization. A health plan gives prior authorization when a service is medically necessary. Without it, your health plan may not pay any of the costs. You can ask your provider if you need prior authorization. Some providers will ask the health plan for prior authorization.
For non-emergency situations, you will generally need prior approval before visiting an outof-network specialist. You must follow your health plan’s process for seeking approval. This can be found by calling the number on the back of your insurance card. Learn more about the referral process here.
Learn how to use your insurance card here.
Get free help with your health coverage!
The Maryland Insurance Administration has a Health Coverage Assistance Team (H-CAT) to assist consumers. If you have questions or concerns about health coverage for you or your loved ones, the H-CAT staff is here for you.
- Get answers to your health insurance questions.
- Address health insurance problems or concerns.
- File a complaint about your health insurance issue or concern.
- Connect you to resources.
Phone: 410-468-2442
