Plan Rules

Medicare prior authorization and referrals explained

Prior authorization and referrals are different plan requirements. Prior authorization is the plan’s advance approval for certain services, supplies, or drugs; a referral is direction from a primary care provider to a specialist or service. Depending on the plan and treatment, you may need one, both, or neither.

What is prior authorization?

Before scheduling non-emergency care, ask the plan and provider whether authorization is required, who submits it, what clinical documentation is needed, and how long the approval remains valid. An approval does not guarantee every charge will be covered: network status, medical necessity, benefit limits, and the actual service billed still matter.

What is a referral?

A referral is direction from a primary care provider to see a specialist or receive certain services. Many HMO plans require referrals; PPO plans commonly do not, but requirements vary.

• Confirm the specialist is in the plan network.

• Ask whether both a referral and prior authorization are required.

• Verify that the facility and all participating providers are covered.

• Check approval requirements again if treatment changes.

• Follow the plan’s appeal or coverage-decision process when coverage is denied.

Keep the authorization number, approved service, provider, facility, dates, and any limits. Recheck if the treatment, location, or clinician changes. Emergency care should not be delayed for routine authorization. If coverage is denied, follow the notice and appeal instructions; Medicare’s appeals guidance explains the available paths.

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