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Clinical Criteria


HMO members: Need to see a specialist? No problem. With HAP, specialty office visits don't require referrals from your primary care physician (PCP). But in some cases, the specialist you see may require a referral from your PCP. Many specialists are booked out months in advance, and may only accept patients whose PCP believes they need specialty care.

PPO members: You don't need to worry about referrals, but your PCP would be a good resource to find a specialist who is right for you. With a PPO plan, you have the flexibility to seek care from doctors in and out of the network. But remember, you might pay more if you choose a doctor outside of our network.

Prior authorization

Before you go to the doctor or have services performed, it's important to understand our approval process. There are common treatments and procedures that require approval before you get them. This is also known as prior authorization.

If your service requires prior authorization, your doctor will take care of it on your behalf.


When Mary visits the ear, nose and throat (ENT) doctor for the first time, she pays her specialist office copay. After her consultation, the ENT recommends a sinus surgery for Mary. Before she has the surgery, the ENT's office must get prior authorization from HAP to make sure the service is covered and that it's medically necessary.

For hospital stays

For inpatient hospital stays, your doctor will get prior authorization from HAP. Emergency room visits don't require prior authorization. Simply, notify HAP within 48 hours of the emergency admission.

Benefit Coverage Policies

HAP's Benefit Coverage Policies can be highly technical and are designed to be used as a guide by our professional clinical staff in making coverage determinations.

They are written on selected clinical issues, especially addressing new technologies, new treatment approaches used with existing technology, and procedures.

Please be advised that some services must be performed in certain clinical settings and/or by specific provider specialties. Providers must follow HAP's referral and practice guidelines as well as the Utilization Management Lists when providing services to our members to ensure appropriate reimbursement.

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