HAP Balanced Living blog

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Referrals and prior authorizations

You want to get the care you need when you need it. We make it easy.

HMO members

Referrals

Need to see a specialist? No problem. With HAP, specialty office visits don’t require referrals from your primary care physician. 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.

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

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.

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