Referral is the process of sending a patient to another practitioner (ex. specialist) for consultation or a health care service that the referring source believes is necessary but is not prepared or qualified to provide. Your primary care physician will refer you to a participating specialist or a health care service doctor/provider if he or she cannot personally provide the care you need. Many referrals do not require an authorization number.
Authorization, also known as precertification, is a process of reviewing certain medical, surgical or behavioral health services to ensure medical necessity and appropriateness of care prior to services being rendered. The review also includes a determination of whether the service being requested is a covered benefit under your benefit plan. Authorizations are only required for certain services. Your physician will submit authorization/precertification requests electronically, by telephone, or in writing by fax or mail. If approved, an authorization number is then generated by Capital Health Plan and is available to you via CHPConnect. If the requested service is not authorized, the member and doctor/provider are notified in writing with the specific reasons for the denial and appeal rights.
Authorization numbers are not required for the following; the services can be completed with a referral or an order from your primary care physician or specialist:
- Most office visits and office-based procedures for local network participating practitioners [1]
- Ambulatory Surgical Center procedures performed at local network participating facilities
- Outpatient hospital procedures and services (excluding Wound Care and Hyperbaric Oxygen treatment, which continue to require an authorization) performed at local network participating hospitals
- Outpatient services at participating out-of-area practitioners and facilities, i.e. University of Florida Health a.k.a. Shands.
- Tallahassee Memorial Center for Pain Management, AKA Tallahassee Neurology Pain Management Facility
- Mammography (screening and/or diagnostic) or ultrasound to detect abnormality in the breast, including those performed at a local participating hospital
- Mastectomy bras and prosthetics as allowed under the member's group benefit package at local participating doctors and providers
- Blood and blood products received in a local participating outpatient hospital facility
- OB labor checks at a local participating outpatient hospital facility
- Ostomy supplies obtained from Medical Care Products
- Certain DME items and oxygen obtained from American Home Patient Care (in the service area), Barnes Healthcare Services, and Desloge Home Oxygen & Medical Equipment
- Sleep studies performed at Tallahassee Memorial Outpatient Sleep Center
- Hospice home-based services
- Dialysis services [2]
- Physical therapy and occupational therapy obtained from TMH Outpatient Rehabilitative Services and the Center for Orthopedic and Sports Physical Therapy
- Most outpatient diagnostic imaging at local participating radiology locations (TDI, THI, Radiology Associates, Stand-Up MRI of Tallahassee)
- Intensive outpatient substance abuse treatment with local participating network practitioners
- Services rendered in a medical emergency
- Laboratory services performed through the LabCorp network (physicians and hospitals must use LabCorp for routine lab work).
Authorization numbers are required for the following:
- All inpatient services
- Outpatient hospital-based services for Wound Care and Hyperbaric Oxygen treatment (HBO)
- All non-participating practitioners or facilities in or out of CHP's service area
- Nutritional counseling when not provided by the TMH Diabetic Center
- All services related to the mouth and/or teeth
- Speech therapy
- All home health care services except hospice care
- Services that may be investigational or outside the realm of accepted mainstream medical care
- All procedures or surgeries that have CHP clinical criteria require review and an authorization at any location. See a listing of Capital Health Plan Clinical Criteria.
The following are just a few of the services that have clinical criteria and require a review and a prior authorization:
- Genetic testing
- Back (lumbar) and neck (cervical) surgery, also known as spinal surgery
- Transcranial Magnetic Stimulation
- Implantable hearing devices
- Certain Durable Medical Equipment (DME), such as: External Insulin Infusion Pumps & Supplies, Continuous Glucose Monitoring, and Power Wheelchairs
[1] Contact Capital Health Plan’s Member Services Department for further information on which local participating practitioner services still require an authorization
[2] Dialysis services temporarily needed while outside of Capital Health Plan’s service area may necessitate receiving services from a facility other than DaVita or Frescenius Kidney Care- you should work with your local dialysis facility to coordinate these services prior to leaving the service area.
[3] You and your primary care physician have access to Capital Health Plan’s Utilization Management clinical criteria through CHPConnect. You may also request a list of Capital Health Plan’s clinical criteria by contacting the Member Services Department.
Last updated: 6/14/23