Referrals and Preapprovals
A referral is when your primary care provider (PCP) sends you to another provider for care. Preapproval is sometimes called “authorization.” This is when a doctor asks us to OK a medical service before you get it.
What is a referral?
For some services, you’ll need a referral from your primary care provider (PCP) before getting care.
When a referral is needed, your PCP will sign a referral form and send you to a provider who works with Healthy Blue. If it’s a self-referral service, you won’t need your PCP’s approval.
For most services, you'll go to your PCP or another provider who works with Healthy Blue. But, there are some services that we'll pay for, even if you get them from a provider who's not in our plan. These are called self-referral services. These include:
- Family planning
- Pregnancy services
- Emergency services
- School-based health center services
- Behavioral health and substance use services
- Certain providers for children with special healthcare needs
We'll also pay for any related lab work and medicine you get from the same site you get the self-referral service.
What is a preapproval?
Preapproval is sometimes called "preauthorization." Some Healthy Blue services and benefits require preapproval. This means that your provider and/or you must ask Healthy Blue to approve those services or benefits before you get them.
Preapproval is needed for some services like:
- Chiropractic services
- Diagnostic testing
- Some home health services
- Nurse-midwifery services
- Some prescriptions
- Rehabilitation therapies (physical, occupational, speech)
For more information about services that need preapproval, please see your member handbook.