Referrals and prior authorization

What happens when you’re referred to a specialist?

Referral to an in-network provider is seamless

No referral or authorization is necessary when you’re referred to an in-network specialist. Go to the Provider Search and select your plan to see specialists in your network, or contact Customer Service for assistance.

About prior authorization

This is the process of receiving written approval from Health Tradition Health Plan for certain services before they are received. Some services require prior authorization even when provided by an in-network provider.

Some specialty medications require prior authorization.

Health Tradition Services Requiring Preauthorization PDF

Services requiring prior authorization include but are not limited to the following:

  • Allergen Immunotherapy Services
  • Arthroscopic Procedures (Knees, Hips and Shoulders)
  • Autologous Chondrocyte Implantations
  • Behavioral Health Care:
    • Partial Hospitalization
    • Intensive Outpatient
    • Residential Services
  • BAHA (bone anchored hearing aids)
  • Cochlear Implants
  • Continuous Glucose Monitoring Systems
  • Continuous Passive Motion Device (knee use only)
  • Dental/Oral Surgery
  • DME and Orthotic Devices with a purchase OR rental price greater than $1,000
  • Dialysis (outpatient and home dialysis)
  • Experimental OR Investigative Services
  • Genetic Testing
  • Helmet for Positional Plagiocephaly
  • Home Health Services including Wound Care
  • Home INR Demonstration and Monitoring
  • Home Infusion
  • Hospice Services
  • Invasive back procedures (injections, surgery, radiofrequency ablation)
  • Inpatient admissions (including observation stays that extend beyond 48 hours)
  • Negative Pressure Wound Therapy
  • Non-emergency Ambulance Transportation
  • Non-invasive Airway Assist Devices
  • Nutritional support and counseling
  • Oncology Related Services:
    • *All treatment regimens (including chemotherapy, radiation, services, procedures, etc.) being requested for a member with a cancer diagnosis requires pre-approval
  • Orthognathic Surgery
  • Psychological and Neuropsychological Testing
  • Reconstructive or plastic surgery such as, but not limited to:
    • Abdominoplasty
    • Blepharoplasty and ptosis repair
    • Brachioplasty
    • Breast augmentation, lift, or other breast reconstructive surgery
    • Panniculectomy
    • Thighplasty
  • Pneumatic Compression Devices and Appliances
  • Reduction Mammoplasty
  • Skilled Nursing Facilities
  • Skilled rehabilitation services
  • Sleep Studies
  • TMJ treatments
  • Transplant evaluations, services and procedures
  • Treatment of varicose veins
  • Upper Airway Stimulation (UAS) Therapy

All services/procedures/surgeries for a member with a cancer diagnosis must be reviewed and approved by Interlink Cancer Care effective 11/1/2018.

The Certificate of Coverage fully defines services requiring referrals or prior authorizations to obtain coverage. Payment for those services will not be made unless prior authorization is obtained. Prior authorization alone does not guarantee payment of benefits.

Specialty Medications that Require Prior Authorization

  • Actemra
  • ACTCHAR HP
  • Antiarrhythmic Drug
  • Antihemophilic
  • Botox
  • Entyvio
  • Epogen
  • Factor VIII
  • Factor IX
  • Fasenra
  • Hemlibra
  • Herceptin
  • Infliximab
  • Interferon and Peginterferon for Hepatitis B
  • Lemtrada
  • Lupron
  • Nucala
  • Ocrevus
  • Orencia
  • Orencia IV
  • Prolia
  • Reclast-Zometa
  • Remicade
  • Rituxan
  • Simponi Aria
  • Soliris
  • Stellara
  • Sublocade
  • Vivitrol
  • Xolair
  • Yervoy

Customer Service

You may verify eligibility, benefits, and what services require prior authorization by contacting Customer Service at:

  • 877-832-1823 (for group, individual, and 65Plus Medicare Supplement plans)

How out-of-network referrals work with specific plans

Health Tradition offers many plan choices, with different provisions for out-of-network services. See your plan’s Summary of Benefits and Coverage or Certificate of Coverage, or call Health Tradition Customer Service if you have questions.

Health Tradition for Employer Groups, Health Tradition for Individuals, Premier, Premier One, and 65Plus members:
Referrals must be approved by Health Tradition Health Plan before the member receives the covered services requested by an in-network health care provider. Preventive services are not covered out-of-network.

Health Tradition Point of Service (POS) for Employer Groups and Premier Plus plan members only:
To receive coverage at the higher in-network benefit level for health care services received from out-of-network providers, a member must obtain a referral from an in-network provider.

However, Health Tradition Health Plan must approve the referral before the covered services listed in the referral are eligible for payment at the in-network benefit level. Coverage at the in-network benefit level is limited to the type, frequency and duration of the health care services approved in the referral.

Refer to your schedule of benefts and coverage or contact Customer Service.

Emergency services

Emergency care is medical treatment required unexpectedly and immediately because of an accidental injury or emergency illness.

A member may receive emergency care at any hospital without prior authorization. If the member is admitted to the hospital, the member must notify Health Tradition Health Plan within 48 hours, or as soon as medically possible, by calling the Utilization Management Department toll-free at 888-459-3020. Prior authorization is required for subsequent follow-up by an out-of-network health care provider. Emergency care is covered at any hospital for a full-time adult dependent/student outside the service area.

Urgent care

Urgent care situations are conditions that will worsen if you delay medical attention until the next available appointment, but are not life-threatening emergencies. A member may receive urgent care services without prior authorization.

Inpatient services

To receive coverage for non-emergency covered services from a hospital, prior authorization is required at least two days prior to an admission to begin prior authorization review.

For hospitalization following emergency care, the member should notify Health Tradition Health Plan within 48 hours, or as soon as possible, by calling our Customer Service department toll free at 877-832-1832.

Mental health and chemical dependency services

Inpatient services

Covered services must be provided in a hospital or mental health or chemical dependency facility. To receive coverage for non-emergency covered services, it is the member’s responsibility to ensure that the referring provider has contacted Health Tradition Health Plan at least two days prior to an admission to initiate the prior authorization review.

For emergency care that requires hospitalization, the member must notify Health Tradition Health Plan within 48 hours, or as soon as medically possible. Members must call our Customer Service department toll free at 877-832-1832.

Transitional treatment services

No prior authorization is required when services are provided by an in-network provider.

Mental health and chemical dependency outpatient services

For individual and family counseling sessions, prior authorization is not required when the services are received by an in-network provider. Prior authorization for neuropsychological testing/psychological testing may be required.

If a member is utilizing an out-of-network healthcare provider, it is the member’s responsibility to ensure that prior authorization has been obtained. Please contact Customer Service for assistance at 877-832-1832.

Coverage outside of the service area for adult dependents who are full-time students

If an adult dependent full-time student plans to utilize non-emergency services from an out-of-network health care provider, it is the member’s responsibility to obtain prior authorization from Health Tradition Health Plan.