Many of the health plans we participate with require authorization BEFORE certain procedures and/or referrals to a specialist. If these guidelines, which should be explained in your health plan handbook, are not followed your health plan may decline to cover "unauthorized" services. Do not make any appointments with specialists until you have spoken to someone in our referral department.
Also, please remember that even if your health plan has issued an authorization number, this is not guarantee of payment. Each claim is still reviewed upon receipt by your insurance carrier, at which time determination for eligibility is made accordingly.
Authorizations, depending on the health plan, the circumstances, and the health plan's workload, may take from one day to two weeks.
In order to assess and determine the medical needs of a patient, NDPA's doctors must examine a child before providing a referral for non-life or limb threatening conditions. NDPA's doctors do not make retroactive referrals.
HMO = Health Maintenance Organization
POS = Point of Service
PPO = Preferred Provider Organization
PCP = Primary Care Physician
PCP required. Patient MUST see PCP for general care, such as, well care and sick care. For services outside of PCP's specialty (ENT, Orthopedic, Allergist, etc...) must have a referral from their PCP for these services to be considered for payment. Must also use "in plan" laboratory, x-ray & hospitals to be considered for maximum benefits.
In most cases, PCP required. Patient MUST see PCP for general care, such as, well care and sick care. Can see any specialist they desire, but for maximum benefits of plan, need a referral from their PCP. Must also use "in plan" laboratory, x-ray & hospitals to be considered for maximum benefits.
No PCP required. No referral needed to see specialists, however, higher benefits will be considered for using "in plan" physicians and using "in plan" facilities.