For questions about Referrals and Prior Authorization – please call our Case Management Department at (760) 291-6615 during normal business hours.
Your Palomar Health Medical Group – Graybill Primary Care Physician (PCP) can meet most of your medical care needs. If you need laboratory, X-rays, physical therapy, durable medical equipment or other services, your PCP can refer you directly to these providers and services.
If your PCP determines you need to see a specialty provider, or if you are a patient with complex medical or health issues, our Case Management Team is available to help you secure the resources you need.
Referrals to specialty care
Sometimes your PCP may determine that you need the care of a Specialist, such as a cardiologist or endocrinologist. In most cases, your health insurance plan will require a referral from your PCP and advance approval of the recommended service by a qualified medical professional. This process is commonly known as Prior Authorization.
Prior Authorization helps to assure that the recommended medical services are:
- Medically necessary
- Rendered at the appropriate level of care
- Provided in a timely manner
- Cost effective
IMPORTANT: If Prior Authorization is not obtained, the services may not be covered by your insurance.
Management of complex health issues
If you are a patient with complex medical issues, it can be a challenge to coordinate all the medical care and services you need to achieve a better quality of life. Our Case Management Department is available to help you secure the resources you need in a timely, effective manner so you can focus on healing and wellness.
Palomar Health Medical Group – Graybill Case Managers are Registered Nurses who work on the behalf of patients with complicated medical needs. Some of their activities include:
- Serving as a liaison and resource for patients, family members, and physicians
- Communicating information to caregivers to obtain consensus on a plan of care
- Developing a plan of care with realistic and appropriate goals and outcomes
- Conducting utilization review before, during and after recommended care options to assure quality, cost effective outcomes