Approvals and authorizations needed for TotalCare (HMO D-SNP) care services

If you are assigned to a TotalCare primary care provider (PCP), you must get a referral to see another provider. Some services don’t need a referral, like emergency or urgent care, certain vaccines, and routine care for women (like checkups or screenings). To see a full list and to learn more, check your Evidence of Coverage (Member Handbook).

If your PCP thinks you need to see another provider, they will fill out a Referral Consultation Form. Your PCP will send a copy to the other provider and to TotalCare. This form lets them know your PCP and TotalCare approved the visit. We need the referral to pay the claim from the other provider.

TotalCare has to approve some services, procedures, medications and equipment before you get them. This is called prior authorization. Usually, the provider who will give you the service sends us a request for prior authorization. They will explain what you need and why. TotalCare reviews the request and any medical records the provider sends. If the service, procedure, medication or equipment is medically necessary and a covered benefit, we will approve the request. We will let you and your provider know, and then you can get the service. For more information about prior authorization, other review rules and what to do if you get a bill from a provider, see your Member Handbook.

If we don’t approve a request, we will let you and the provider know. You can file an appeal if you don’t agree with our decision.

If the service is not urgent, we will make a decision within 7 calendar days after we get the request.

If your doctor or health care provider tells us that waiting could hurt your health, we will make a decision within 72 hours.

Your doctor tell you about our decision. Sometimes, we may also call you. If services are denied, we will send you a Notice of Denial of Medical Coverage by mail within two business days of the decision. This letter will explain why the service was denied in whole or in part, and what you can do if you don’t agree. A copy will be sent to the provider when an Authorization Request is being reviewed at the same time as you are getting services (this is called “concurrent review”). We will make sure that necessary care is not changed or stopped until your doctor creates a care plan that fits your medical needs.

For more information, please see the Member Handbook or talk to your provider.

If your provider couldn’t get prior authorization before giving you care, they have 30 days after the service to send us a request. We will review it and decide if we can approve it. Some surgeries need approval ahead of time, but in some cases, where your doctor couldn’t submit a prior authorization request before your surgery, they can send it after your surgery, and we will review it.

If you received services and were not eligible for benefits at the time the service was provided, but you now have coverage for that date, your provider must send us the request within 60 days from the date eligibility was approved.

We’ll let you and your doctor know if we approve, change or deny the request within 30 days.

You’ll get a letter with our decision. If we deny the request, we will send you and your doctor a Notice of Action (NOA) letter. This letter will explain why it was denied and how to appeal if you don’t agree with our decision.