More about referrals and authorizations
While most medical care can be obtained without our involvement, we want to ensure you receive quality care in the most appropriate setting. Doctors, nurses, and other staff in Health First Health Plans’ (HFHP) Medical Management Department work with your doctor and other healthcare professionals to coordinate your care.
To make it easy for you to obtain medical care, HFHP does not require referrals to in-network providers for covered services. A referral is when your doctor sends you to another doctor or facility for treatment. If you have an Point-of-Service (POS) plan, you may also see out-of-network providers without a referral. (Although HFHP does not require referrals, some specialists may require you to be referred by your Primary Care Physician (PCP) to ensure your care is coordinated properly.) If you have an HMO plan, you must use network providers for covered services. You may only see an out-of-network provider if participating network providers do not offer the service being requested. These services will require a prior authorization. It is your responsibility to work with your provider to obtain prior authorization for these services.
Whether you have an HMO or POS plan, there are some services that require authorization before you receive them. Network providers are familiar with the process. The authorization process starts with your doctor. Our Medical Management Department will review your physician’s request. If the request is denied, you’ll receive a letter from us explaining your right to appeal and how to do that. To ensure the highest level of coverage, make sure authorization is obtained in advance when required.
HFHP assures providers, practitioners, and members that all decisions involving HFHP coverage are based on appropriateness of care and service. We do not compensate practitioners or any other individuals for making decisions that could result in denials of care. Denials are based on medical necessity or contract provisions. HFHP works to prevent inappropriate decision making by regularly monitoring all medical claims and requests for care. We are committed to providing you access to quality care.
If you have questions about the referral or authorization process, you can reference your Evidence of Coverage for additional information, or you can contact Customer Service at 321-434-5665 or 800-716-7737 (TDD Relay is 800-955-8771) from 8 am to 8 pm every day. A Medical Management Department nurse is also on call 24 hours a day, seven days a week, and can be reached at the same numbers above.