Referrals and Authorizations

Referrals

A Referral is a special permission that is normally given by your Primary Care Provider (PCP) for you to see a Specialist. Examples of Specialists are Cardiologists, Dermatologists and Allergists. NHP requires a referral for you to receive care from any NHP In-Plan specialist.

Your PCP should help you coordinate your health care. When you have an established connection with your PCP, he or she can help you address all aspects of your health care and assist you in coordinating all the services you need. Before making an appointment with an In-Plan specialist, your PCP should discuss the situation, consider options, and help you decide where you can get the services you need. Your PCP must then begin the process for obtaining the referral. They can communicate directly with specialists and are required to obtain a referral ID number from NHP for these services.

It is your responsibility to make sure that the specialist you wish to see participates with NHP and is available in NHP’s network. When you use In-Plan providers, you know that they have been credentialed by NHP and that they will work with our medical staff to help ensure you get the care you need. To find a specialist, you may search our online provider directory or call the NHP Member Service Center at 1-800-462-5449 (TTY 1-800-655-1761)

Authorization

An Authorization is a special approval by NHP for payment of certain services. Not all services require Authorization. When an Authorization is needed, it must be given before you receive the service in order for NHP to cover it. Your PCP or the Specialist treating you will request an Authorization if it is necessary.

Examples of services requiring Authorization from NHP are physical therapy, speech therapy, surgical procedures, planned admissions, and inpatient psychiatric care. NHP gives Authorizations as soon as possible. NHP must also authorize your use of any provider who is not part of NHP's Network. In order to make sure you receive consistent care, there are some conditions when NHP will provide authorization for you to see a provider that is not part of NHP's Network. You can call the NHP Member Service Center for help in understanding if your condition qualifies you to see a Provider out of the NHP Network. If you receive services from a provider who is not part of NHP's Network and you did not have Authorization from NHP first, you may have to pay for the service.

Complete list of services requiring prior authorization