What services require prior approval or a referral?
Members must obtain referrals from their PCPs. Referrals are made when the PCP deems services of a specialist medically appropriate. The PCP arranges for the referral and gives the member a completed referral form that authorizes specific treatment or services. There are certain situations where a referral is not necessary.
As a rule, the Member should always call the PCP before seeking any medical treatment. Although not required, your PCP can provide most medical services and can assist you with specialist recommendations. You may also visit a specialist when necessary without prior approval from your PCP. If you need emergency or urgent care while you are traveling away from home, you may seek care from a local urgent care facility.
Hospital admissions in almost all instances require pre-certification in advance from UNICARE if you want to receive the maximum benefits available. Your Certificate of Coverage or plan booklet will indicate if your plan also requires pre-certification of certain outpatient surgical and diagnostic procedures. Some plans require pre-certification of services like private duty nursing, home health care and skilled nursing facilities. Of course, the final decision about care you receive is between you and your doctor. UNICARE only determines what will be eligible for benefit payment under your plan, based on medical necessity. In addition, to ensure that prescription drugs meet accepted national standards of quality and effectiveness, some plans require your physician to provide a letter of medical necessity to UNICARE when prescribing certain drugs. Please refer to your plan booklet for more detail. This is only a brief summary of the plan. Please refer to your Certificate of Coverage or
When you use a network physician or hospital, they are responsible for ensuring that any surgical procedure or inpatient admissions receive the necessary prior approval. When using an out-of-network physician and hospital, it is your responsibility to receive prior approval from Blue Cross and Blue Shield of Georgia for home health care services and inpatient care (excluding maternity related care) prior to these services being rendered.
HMO, Elect Choice EPO: All specialty services require referrals, except for direct access programs such as ob/gyn. Prior approval by Aetna is not required for referrals. All inpatient admissions and certain other services require approval excluding normal maternity admissions, which require notification only. Participating physicians are responsible for obtaining precertification/prior approval. QPOS, USAccess, Managed Choice POS: To receive the higher benefit level under the plan of benefits selected by the Employer, members should obtain a referral from their PCP for all specialty services except direct access programs such as ob/gyn, lab and X-ray. Prior approval by Aetna is not required for referrals. Members may also visit any recognized provider, without a referral, at a reduced benefit level. All inpatient admissions and certain other services require precertification/approval excluding normal maternity admission, which require notification only. Participating physicians are res
