Referrals and Authorizations

Referrals and Authorizations

It is important to understand the difference between a referral and an authorization, and how to obtain each one.

Referral is the process of sending a patient to another practitioner (ex. specialist) for consultation or a health care service that the referring source believes is necessary but is not prepared or qualified to provide. Your primary care physician will refer you to a participating specialist or a health care service provider if he or she cannot personally provide the care you need. Many referrals do not require an authorization number.

Authorization, also known as precertification, is a process of reviewing certain medical, surgical or behavioral health services to ensure medical necessity and appropriateness of care prior to services being rendered. The review also includes a determination of whether the service being requested is a covered benefit under your benefit plan. Authorizations are only required for certain services. Your physician will submit authorization/precertification requests electronically, by telephone, or in writing by fax or mail. If approved, an authorization number is then generated by Capital Health Plan and is available to you via CHPConnect. If the requested service is not authorized, the member and provider are notified in writing with the specific reasons for the denial.

Authorization numbers are NOT required for the following; they can be completed with a referral or an order from your Primary Care Physician or Specialist:

• Most office visits and office based procedures for local network participating practitioners [1]
• Carpal Tunnel and/or Trigger Finger treatment to a local network participating plastic surgeon effective 03.01.11
• Most Ambulatory Surgical Center procedures [1]
• Tallahassee Memorial Center for Pain Management AKA Tallahassee Neurology Pain Management Facility
• Mammograms
• Ostomy supplies obtained from Medical Care Products
• DME and oxygen obtained from American Home Patient Care (in the service area), Barnes Healthcare Services and Desloge Home Oxygen & Medical Equipment
• Sleep Studies performed at Tallahassee Memorial Outpatient Sleep Center
• Hospice home based services
• DaVita dialysis services [2]
• Physical Therapy and Occupational Therapy obtained from TMH outpatient Rehabilitative Services and the Center for Orthopedic and Sports Physical Therapy
• Most outpatient diagnostic imaging at local participating radiology locations (TDI, THI, Radiology Associates)
• Intensive outpatient substance abuse treatment with local participating network practitioners
• Services rendered in a medical emergency

Authorization numbers ARE required for the following:

• All inpatient services
• All outpatient hospital based procedures and surgeries with the exception of TMH Sleep Center
• All services received at the following Ambulatory Surgical Centers: Alamarcon, Southeastern Outpatient Surgery Center and Tallahassee Plastic Surgery Facility with the exception of Carpal Tunnel and or Trigger Finger surgery.
• All non emergency services received outside CHP’s service area, including out of area contracted practitioners and facilities (ex. Shands)
• All services related to the mouth and/or teeth
• All Plastic Surgery specialty services with the exception of Carpal Tunnel and/or Trigger Finger Surger
• Cain, Angelina MD, Bariatric Medicine.
• Colonoscopies for members 55 yrs old or older (effective September 1st 2011)
• Speech Therapy
• Natalie Lawson RD
• Back (lumbar) and neck (cervical) MRIs
• Back (lumbar) and neck (cervical) surgery also known as spinal surgery
• All home health care services (except hospice care as listed above)
• Services that may be investigational or outside the realm of accepted mainstream medical care
• All procedures or surgery that has CHP clinical criteria requires review and an authorization at any location. See a listing of Capital Health Plan Clinical Criteria on the Medical Policies page.

[1] Contact Capital Health Plan’s Member Services Department for further information on which local participating practitioners still require an authorization for services

[2] Dialysis services received outside of Capital Health Plan’s service area may necessitate receiving services from a facility other than DaVita – you should work with your local DaVita facility to coordinate these services prior to leaving the service area.

[3] You and your Primary Care Physician have access to Capital Health Plan’s Utilization Management clinical criteria through CHPConnect. You may also request a list of Capital Health Plan’s clinical criteria by contacting the Member Services Department.