Your Doctor Helps Make Sure Your Services Are Covered

Your Doctor Helps Make Sure Your Services Are Covered

Your Doctor Helps Make Sure Your Services Are Covered

Your doctors know a lot about the steps needed to help make sure your health plan covers the care they give you. As a smart health care consumer, you’ll want to know about the things they do to make sure your health care coverage works for you when you need care.

Some types of health care or treatments may require a pre-service review. That means your doctor will send information to us about the care they are recommending before you receive care.


When you schedule an appointment, your doctor’s office will ask you for your health plan information before you are seen by a doctor. They use this information to make sure your health care coverage is active and can be billed for your visit.

Once this is confirmed, your doctor or other health care provider will see you to talk about what is bothering you. They may do a physical exam, like listening to your heartbeat and breathing. Then they will either diagnose you or decide they need to do some tests, like blood work or X-rays. These tests will give them more information about your health issue so you and your doctor can decide on a treatment.

After a doctor sees you and decides how to treat you, sometimes they need to share with us what they found that made them decide you need a certain treatment. That information may include the results of blood tests, imaging tests or a physical exam. Your doctor will also give us any additional details we need.

This exchange of information to make sure care is covered by your plan is called preauthorization. A preauthorization may be needed to have certain procedures approved or to admit you to the hospital. If preauthorization is required and isn’t done, you may have to pay more of the cost of your treatment.

Preauthorization helps us help you get the right care at the right place. We’ll use the information from your doctor to answer these questions about the treatment:

Is it needed? The doctor will give us details about your health issue so that we have enough information to see if the care meets the “medically necessary” guideline. For example, you may not need an MRI or CT scan for your issue if it isn’t needed to make a diagnosis or if another doctor has already had them done.

Is it covered? Not everything a doctor can do is covered by all health plans. Some don’t cover weight loss surgery, for example.

Is it in your health plan’s provider network? If your doctor sends you to a specialist or hospital that isn’t in your network, you could end up paying a lot more — or even all — of the charges.

Is it the right level of care? Do you really need to see a specialist or go to an imaging center? Should you be admitted to a hospital or is it something that can be done at an outpatient center?

How long will it take? Your doctor’s care plan will estimate how long it will take for you to get care and get well enough to go home. If it is taking longer than estimated, they’ll let us know and we can add more covered days to make sure all the days are covered. This is especially helpful for people who have had surgery, since recovery times may depend on how well you heal.

Getting the answers to these questions helps us work with the doctor to make sure you get access to the right care. Our role is to help make sure your care is covered by your health plan.


When your primary care physician (PCP) wants you to see a specialist, your PCP will likely write a referral.

For HMO plans, this referral is required. Some point-of-service (POS) plans may also require a referral to get coverage at the full benefit level.

Before you see a specialist, you will likely get a referral notice from your PCP that you’ll need to take with you to your new patient visit with the specialist. Or your doctor may email or fax it directly to the specialist’s office.

Before you can be seen, the specialist’s office will make sure that:

  • A referral was made.
  • We have the referral information.
  • You are eligible for care.

To be sure, ask the specialist’s office to check that these steps have been done before your visit. That way you’ll know before your visit if you need to call your PCP’s office back to send the referral. This will help make sure you don’t go to a doctor’s visit only to be told you can’t be seen.

For health plans other than HMO and POS, a referral usually isn’t needed. But doctors may still give you one or call it in to the specialist’s office. It is simply a way for the specialist to have all of the facts about what they are being asked to check.

A referral gives specialists, hospitals and other facilities the information they need to get preauthorization, if needed, and do their part in your care. It also creates a chain of care so that your doctor is kept informed about any findings, treatment plans and hospital admissions.

Consult BAM pre-service reviewsFind Out What You Need

Not all procedures require pre-service reviews. For a full list of procedures that require pre-service review, check your benefit information by logging in to your Blue Access for MembersSM account. Select the My Coverage tab and click on the prior authorization link under My Coverage Benefits.

What About Prescriptions

Some drugs may need preauthorization, or prior authorization.

A drug may not be covered under your plan or may not have been proven effective for your health issue. The only way your doctor or pharmacist may know is by getting approval first.

Here are some reasons a drug may not be approved:

  • There are concerns about cost or safety: There may be another drug that may be safer or cheaper and just as effective.
  • It is not on your plan’s approved drug list.
  • We want you to try a generic first instead of a brand-name drug, which can save you money.
  • You may not have coverage for any drug in that drug class, such as drugs for weight loss, drugs for cosmetic purposes or most over-the-counter (OTC) drugs.
  • It may be considered a special case, like certain cough medicines or cold and allergy medicines.
  • The drug may be on your drug list for some health issues, but not for your issue.
  • The drug is one of the controlled substance drugs that can be addictive. There are limits on how much can be prescribed.

When reviewing drugs and their use, we consider these things and others. So it’s a good idea for you and your doctor to consider your approved drug list when making choices about how to manage your health.

You can check your health plan’s approved drug list before you go see your doctor. It will save time and money when you’re getting your prescriptions filled.

Your Pharmacist Can Help

If your copay seems high when you get a new prescription filled, ask the pharmacist if the drug is covered by your plan.

Your pharmacist can also check to make sure a new drug isn’t harmful if combined with another drug you are already taking. They may have more information than your doctor about what drugs you are taking and how the drugs work when taken together.

If there is an issue, your pharmacist may:

  • Call your doctor’s office about the drug not being covered.
  • Forward your covered drug list to the doctor’s office.
  • Talk to your doctor about a drug interaction that could be harmful.
  • Give you a cheaper, generic drug, unless your doctor writes “use brand only” when writing the prescription.

Prior authorization for drugs is usually handled by the pharmacy. It isn’t required for every drug.

Many times, your prescription can be filled while you wait. Other times, if it is a new prescription, a special drug or new on the market, it may take longer. How much longer depends on the medicine. If you need the drug quickly, the pharmacist can ask for expedited review.

There are hundreds of medications, and more are becoming available every day. By using prior authorization, we can make sure you get a drug that works, is safe for you and has the lowest cost.

Sources: Safety First: Helping Patients Understand Prior Authorization,   eviCore healthcare, 2017; Commonly Abused Prescription and OTC Drugs,   WebMD, 2017
eviCore healthcare, LLC, is an independent company that provides utilization review for select health care services on behalf of Blue Cross and Blue Shield of Illinois.