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.
Services requiring prior authorization include but are not limited to the following:
- Autism services
- Bariatric surgery
- Bone anchored hearing aid (BAHA)
- Dental/oral surgery services for coverage under the medical benefit
- Durable medical equipment, disposable supplies, and prosthetics (for items costing over $750) and certain items regardless of cost
- Experimental/investigational services
- Genetic testing
- Hi tech radiology
- Home health visits, including RN visits and/or occupational/physical/speech therapy provided at home
- Home infusion
- Hospice care
- Implantable infusion pumps
- Implantable sacral nerve stimulation device
- In-home counseling
- Non-emergency (elective) inpatient hospitalization
- Non-emergency ambulance services
- Orthognathic surgery
- Out-of-area services (except for emergency care and urgent care)
- Skilled nursing facility care
- Speech therapy
- TMJ services
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.
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 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 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. If you visit an urgent care clinic, please notify Customer Service to ensure timely and accurate processing of the claim.
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 the Utilization Management Department toll-free at 888-459-3020.
Mental health and chemical dependency 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 the Utilization Management Department toll-free at 888-459-3020.
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.
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.