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Referrals and prior authorizations

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HMO members

Referrals

With HAP, specialty office visits don’t require referrals from a primary care physician. But in some cases, the specialist may require a referral from a member’s PCP. Many specialists are booked out months in advance and may only accept patients whose PCP believes they need specialty care.

Prior authorization

Sometimes specialists may suggest procedures we don’t feel are the best course of action for a patient. That’s why we want members to check with us so we can help manage their care. This is called prior authorization. If a service requires prior authorization, the member’s doctor will take care of it on their behalf.

Example:

When Mary visits the ear, nose and throat 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, the member’s doctor will get prior authorization from HAP. Emergency room visits don’t require prior authorization. Members must notify HAP within 48 hours of the emergency admission.

PPO members

Members with a PPO plan don’t need to worry about referrals. With a PPO plan, they have the flexibility to seek care from doctors in and out of the network. But they might pay more if they choose a doctor outside of our network.

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