Referral vs. prior authorization: What’s the difference?

Referral vs. prior authorization: What’s the difference?

October 2, 2019
doctor consulting with patientIf you are enrolled in HealthSelect of Texas, you must choose a primary care provider (PCP) to get in-network benefits. Your PCP is responsible for coordinating your care, submitting referrals, and ordering lab and imaging services. 

Referrals 

A referral is a written order from your PCP for you to see a specialist. You need to get a referral for most services before you can get medical care from anyone except your PCP. 

If your PCP decides that you need to see a specialist, he or she will need to submit a referral to Blue Cross and Blue Shield of Texas (BCBSTX) before your visit. Your specialist or lab facility must be in-network for you to get the highest level of benefits and pay less out of pocket.  

You do not need a referral for the following services: 
  • chiropractic visits,  
  • eye exams (both routine and diagnostic), 
  • mental health counseling, 
  • OB/GYN visits,  
  • occupational therapy, physical therapy and speech therapy, 
  • virtual visits,
  •  urgent care centers and
  • retail health clinics. 

Prior authorizations 

Prior authorizations help ensure that the treatment you get is appropriate for your specific medical situation. You’ll also get the highest level of benefits when you have a prior authorization on file. You need prior authorization for certain covered health services.

Some examples of covered services that need prior authorization include, but are not limited to: 
  • ​genetic/molecular testing, 
  • high-tech radiology exams (such as a CT scan, nuclear stress test, MRI and PET scan),
  • home health services,
  • long-term acute care,
  • sleep studies, including positive airway pressure devices (like a CPAP or APAP) and initial supplies and 
  • transplant services. 
Your in-network PCP and other in-network providers are responsible for getting prior authorization from BCBSTX for you before you get these and some other services. If you decide to get these kinds of health services from out-of-network providers, you are responsible for getting prior authorization directly from BCBSTX. If you do not do so,  the services you get may not be covered by the health plan or may be subject to an additional $200 deductible and be covered at the out-of-network level of benefits (depending on the type of service).

If you have questions about your benefits, would like to confirm if you need a referral or prior authorization, or want to check on the status of an existing referral or prior authorization, contact a BCBSTX Personal Health Assistant toll-free at (800) 252-8039, Monday – Friday, 7 a.m. – 7 p.m. and Saturday, 7 a.m. – 3 p.m. CT.  You can also see the status of your referrals and prior authorizations by logging in to your Blue Access for MembersSM account at healthselectoftexas.com.