Approvals for Care
There are many terms used in health care and sometimes they can be confusing! We want to make sure you know how to get services that are covered by your health plan. The below information should help you understand when and how to get approvals before you get care.
Referrals and authorizations are not required for emergency care.
If you are assigned to an Alliance primary care provider (PCP), you must have a referral to see another doctor. There are some exceptions. For a complete list and to learn more, see your Member Handbook.
If your PCP thinks you need to see another doctor, they will fill out a Referral Consultation Form. Your PCP will send a copy to the doctor you are being referred to and a copy to the Alliance. The referral is how the other doctor and the Alliance know your PCP has approved the visit. We need to have a referral to pay the claim from the other doctor.
In most cases, your primary care provider (PCP) will refer you to a doctor in our service area: Santa Cruz, Monterey and Merced counties. If your PCP refers you to a doctor out of our service area, he or she needs to get approval from us in advance. This is called an authorized referral, because we must authorize (approve) the referral before you can see the other doctor.
If you are an Alliance In-Home Supportive Services (IHSS) member, you will also need an authorized referral if your PCP is referring you to a doctor that does not work with the Alliance — even if the doctor is in our service area.
Alliance members who are enrolled in the California Children’s Services (CCS) Program will also need an authorized referral for specialty care.
The Alliance has to approve some services, procedures, medications and equipment before you get them. This is called prior authorization. The provider who is going to perform the service must send us a request for prior authorization, letting us know what you need and why. We review the request and any medical records the provider sends. If the service, procedure, medication or equipment is medically necessary and a covered benefit, we approve the request. We let the provider know, and then you can get the service.
If we deny a request, we will let you and the provider know. You can file an appeal if you disagree with our decision.
How long does an approval take?
For services that are not urgent, we make decisions within 14 calendar days from when we get the request.
If your doctor or health care provider tells us that the standard approval timeframe could affect your life or well-being, we make our decision within 72 hours.
How will I know if I am approved?
You receive a letter that lets you know the decision. In some cases, we may also call you. If the services are denied, we send you and your provider a Notice of Action (NOA) letter. This NOA letter tells you why we denied the services and how you can file an appeal if you do not agree.
For more information, please see the Member Handbook.
Contact Member Services
- Monday through Friday, from 8 a.m. to 5:30 p.m.
- Phone: 800-700-3874
- Deaf and Hard of Hearing Assistance
Alliance TTY Line: 800-735-2929
- Nurse Advice Line