Referrals & Precertifications: Requirements
EPO Benefit Tier
When care is needed outside of your Primary Care Physician (PCP), your doctor will refer you to an EPO Network specialty care provider. If your doctor submits a referral request for an out-of-network or a Plus Network provider, the request will be redirected to an EPO Network provider.
Many procedures that can be performed in office or at another contracted facility also require authorization. Your doctor should have access to a list of procedures that do not require precertification.
There will be no coverage for EPO benefit services provided without precertification, if the service requires authorization.
The following specialties do not require a referral from your doctor or prior approval on the EPO benefit tier:
- Chiropractic Care (limited to 20 visits per calendar year)
- Outpatient Mental Health/Substance Abuse (not including Intensive Outpatient Program - IOP)
Plus Benefit Tier
You have the option of accessing your care through your Plus benefit, which gives you an additional listing of providers and facilities that you can consult with and continue care through. When choosing to use this benefit, you can consult with a Plus Network specialist without a referral from your PCP. Just select a doctor from our Plus Network Provider Directory (PDF) of contracted providers and call to schedule a consultation.
If you need additional follow-up with your selected Plus Network provider or you need a procedure, precertification is required. Any authorization request submitted to the Plan by a Plus Network provider will be processed only after confirmation is made that you are electing to use your Plus Benefit.
Any services provided without prior authorization, if required by the Plan, will not be covered.