Sometimes your Palomar Health Medical Group – Graybill Primary Care Physician 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 an advance review, or Prior Authorization, of the recommended service as a condition of coverage. If this important step is skipped, the service may not be covered by your insurance.

The purpose of Prior Authorization is to assure that recommended medical services are:

  • Medically necessary
  • Rendered at the appropriate level of care
  • Provided in a timely manner
  • Cost effective

Referral Procedures

As your Primary Care Provider, your PCP can meet most of your medical care needs. If you need laboratory, radiology, physical therapy, home health, durable medical equipment, or other services, your PCP can refer you directly to these providers and services. If your PCP determines that you need to see a Specialist or require other non-Primary Care services, your insurance may require your PCP to submit a referral request to our Utilization Management Department. Your PCP’s request should include enough documentation to justify why the service is needed.

Here are a few examples of services that typically require a health insurance prior authorization are (list is not all-inclusive):

  • Hospital stays
  • Advanced diagnostics (MRI, CT, PET scans, colonoscopy, endoscopy)
  • Surgical procedures
  • Ambulatory services (dialysis, genetic testing, rehabilitation, infertility treatments, sleep studies)
  • Ancillary providers and services (audiologists, speech therapists, insulin pumps and supplies, home health services, hospice)
  • Behavioral health services (psychiatry, psychology, addiction treatment)

Most referral requests are reviewed for medical necessity by qualified medical professionals within our Utilization Management department. Authorizations are based solely on the appropriateness of care and existence of insurance coverage. For complex cases, we consult with physicians from the appropriate specialty area. It should be noted that only a licensed physician can determine that a request for medical care be denied because it is not medically necessary.