Referral:
The Primary care physicians NPI number needs to be added whenever a specialist receives a patient only then will the Insurance pay. In this situation when the family doctor cannot treat the patient since he is not qualified in any particular field then he would recommend the patient to go to a specialist for example Cardiologist, whenever the PCP sends the patient to a specialist then he would need to give a corresponding referral to the patient so that the patient can then hand it over to the specialists office.
Pre-authorization: Is when the Insurance needs to be contacted prior to rendering of any medical service. Some type of treatments which are of big
dollar value for example Radiation Therapy (for cancer treatment) would be very expensive, therefore the carrier would request the doctors office to obtain previous approval from their Utilization Management department before treating any patient, in this way they could track their expenditure as well as keep track on all big dollar accounts. If the doctor’s office fails to get this authorization then the claim would be denied.
