Referrals and Prior Authorizations in Medicare Advantage

This guide outlines the processes related to referrals, prior authorizations, and care management within the Premera Medicare Advantage program. It details the responsibilities of primary care providers in arranging care with specialists, including the requirements for referrals to in-network and out-of-network providers. Additionally, it specifies the services that require prior authorization, such as acute hospital admissions and elective surgeries, and provides instructions for submitting prior authorization requests. The document also describes the roles of Carelon Medical Benefits and Optum in managing authorizations for specific services. Furthermore, it highlights the care management programs available to members, including complex case management and chronic condition management, aimed at improving health outcomes. The guide emphasizes the importance of timely submission of clinical information for authorization requests and outlines the decision timelines for various types of requests.