Referrals and Authorizations Tip Sheet

This guide provides essential information regarding referrals and authorizations for patients with health maintenance organization (HMO) plans, specifically focusing on Humana Medicare Advantage and commercial plans. It outlines the requirements for obtaining referrals, which are necessary for specialized treatment, and explains the process for preauthorization or authorization for additional medications or services. Key terms are defined, including referral, preauthorization, and authorization, to clarify their meanings within the context of healthcare services. The document details the steps for healthcare providers to obtain referrals and preauthorizations through Availity Essentials, emphasizing the importance of completing requests accurately to ensure approval. It also highlights the responsibilities of primary care physicians and specialists in the referral process, including the need for preauthorization before additional services are rendered. Regular reviews of the information are mentioned, encouraging providers to stay updated on policies and procedures.