Prior Authorizations & Referrals

Before You Begin

Prior authorizations and referrals are often misunderstood by Medicare beneficiaries. They are not designed to prevent members from receiving care. They're tools that help coordinate healthcare, verify medical necessity, and confirm services meet the plan's coverage guidelines. By the end of this lesson you'll understand:

• What referrals are
• What prior authorizations are
• Why they exist
• When they're commonly required
• How to explain them to clients
• Emergency exceptions that always apply