Referrals and Prior Approvals
You may have to get referrals or prior approvals for some services. Learn more about how referrals and prior approvals work and when you may need to get them for your care.
What is a referral?
A referral is when your primary care provider (PCP) sends you to another provider, like a specialist, for care. As an Anthem HealthKeepers Plus member, you don’t need a referral to see a provider who’s not your PCP as long as the provider is listed as one of the doctors in your plan. For a listing of doctors in your Anthem HealthKeepers Plus plan, use our Find a Doctor tool.
What is a prior approval?
Prior approval, or preapproval, is sometimes called precertification or preauthorization. This is when a doctor asks us to OK a medical service or medicine before you get it. Preapproval is needed for some services, like:
- Inpatient admissions
- Some behavioral health services, like skills training
- Psychological testing
- Some prescriptions (called prior authorization)
- Rehabilitation therapies (physical, occupational, respiratory, speech)
- Care from a provider who doesn’t work with your plan
For more information about services that need preapproval, please see your member handbook and formulary.
Your PCP or specialist should send all preapproval requests to us to review. If a service isn’t medically needed, you’ll get a letter from us saying we could not OK the service. You have the right to appeal our decision if you or your provider disagree. You can find more information about filing an appeal in your member handbook, or in the Utilization Management section below.
Read your member handbook to learn more about your benefits. Find the most recent handbook for your plan on your resources page. If you have questions, call us at 1-800-901-0020 (TTY 711).
Utilization management: How we make choices on care and services
Sometimes, we need to make choices about how we pay for care and services. This is called Utilization Management (UM).
Our UM program:
- Looks at what, when, and how much of our services are medically needed.
- Always strives for the best possible health outcomes for our members.
Our UM program does not:
- Tell doctors to withhold or give you fewer services limiting or denying care.
- Stop certain people from getting services.
- Reward doctors for limiting or denying care.
Getting in touch with our Utilization Management staff
Some Anthem HealthKeepers Plus services and benefits need prior approval. This means your provider must ask your Anthem HealthKeepers Plus plan to approve the services he or she wants you to have. Services that don’t need approval are:
- Emergency care
- Family planning services
- Basic prenatal care
- Care needed after a hospital stay
Our Utilization Review team looks at approval requests. The team decides if:
- The service is medically needed
- The service is one that is included in your Anthem HealthKeepers Plus benefits
What should you do if your Anthem HealthKeepers Plus plan won’t approve care you think you need? You or your provider can ask us to take another look. We’ll let you and your provider know when we get your request. You can ask us to take another look at services that:
- Are not approved
- Have been limited in the amount or length of time from what was requested
Do you have questions about an approval or a denial you got? Call Member Services at 1-800-901-0020 (TTY 711). Our Utilization Review team or your care manager/care coordinator can help answer your questions.
Your opinion matters!
Every year, we survey our members about the benefits we offer. If you get a survey in the mail, by email, or phone, please remember to complete it. It can help us make your plan better.