Referrals & Prior Authorization
Sometimes there are steps you need to take before you receive care that could affect whether your health insurance plan pays your claim.
Do you need a referral?
Some plans require you to choose a primary care provider (PCP). Your PCP oversees your care and coordinates your care with other doctors. So, if you need to see a specialist, your first step would be a visit with your PCP to get a referral.
If you don’t get a referral first, your health plan can deny the claim. There are some exceptions, such as for emergency care.
Not sure if your plan requires referrals? Log into My Health Toolkit® to review your Eligibility and Benefits. You can review what your plan covers and what requirements might be in place for different types of services.
What is prior authorization?
In some situations, your plan may require you to get prior authorization. This is a process that allows us to review whether a service or medication is medically necessary before the plan agrees to cover it. There may be other treatment options available. Some may even lower your out-of-pocket costs.
You must complete the prior authorization process before receiving the service or medication. There are some exceptions, such as for emergency care.
You can check the status of a prior authorization request through My Health Toolkit. Log in, and then go to Health, select Benefits and then Authorization Status.
Need to know if authorization is required, review the standard prior authorization list.
2025 Prior Authorization Metrics Process
We share information each year to explain how our prior authorization (PA) process works. These metrics are numbers we gather to show how many PA requests we approve or deny. They also show how long decisions take and what happens when you appeal or ask for a review of a decision.
Services that need prior authorization
Some medical services and equipment need prior authorization. This means your doctor must get consent from us before you receive a service. This helps make sure everything is covered under your plan.
How we report prior authorization metrics
The metrics shown here combine data for all medical items and services that need consent before you get care. This does not include drugs.
Standard prior authorization requests
Standard requests are for care that is not urgent. We review and decide most requests within normal time frames. Sometimes, we deny a request and later approve it after an appeal. Other times, we need more time to decide. When this happens, we may extend the review period for up to 7 days. Federal rules allow this.
This table shows how many standard prior authorization requests we approved or denied in 2025. It also shows requests approved after an appeal or after an extended review.
Expedited prior authorization requests
Expedited requests are for urgent medical needs. We review these requests in 72 hours. We may not report appeal or extended review data for these requests. Reporting this information is optional.
This table shows how many expedited prior authorization requests we approved or denied in 2025.
Time to decision
This table shows how long decisions take. Time starts when we get the request and ends when we make a decision.