Referrals and Authorizations

Referrals and Authorizations

A referral is a written order from your physician to another in-network John Muir Health physician. An authorization is a request for service that requires formal review by John Muir Health.

For many services, insurance authorization is required. This helps us ensure that medically necessary services are provided at the most appropriate level and match your health plan benefits.

Coverage Decisions

Requests for coverage are based only on appropriateness of care and service. John Muir Health does not specifically reward practitioners or other individuals for denying coverage or service. Financial incentives for decision makers do not encourage decisions that result in denials of coverage.

When reviewing requests for medical services, John Muir Health uses written criteria based on sound clinical evidence. Criteria are applied consistently to service requests based upon the needs of each individual patient. You or your doctor can make a specific request to find out the criteria used to review your request. We accept requests via mail, fax, or telephone.

Send written requests to:

John Muir Physician Network
Care Management Department
1340 Treat Blvd., Suite 450
Walnut Creek, CA 94597

For questions about the care management process or criteria, please contact Customer Service at (925) 952-2887, option 1, TTY/TDD users may call 711.

Out-of-Network Policy

As an HMO patient with John Muir Health, you have access to a full array of doctors, hospitals, surgery centers, and ancillary services. To ensure that the system works as intended, we require you to use these network doctors and services whenever possible.

Requests for authorization to be treated by an out-of-network doctor must be submitted to us by your doctor. We will authorize requests that are clinically appropriate and cannot be provided within John Muir Health.

Denied Claims

Claims submitted for unauthorized out-of-network services will be denied and may become your financial responsibility. Out-of-network doctors have been advised of this policy. They may require you to sign an agreement accepting financial responsibility if you do not have the appropriate authorization for their services.

You can access our list of in-network HMO providers by visiting our Find a Doctor page. You can also verify the in-network status and location of a provider by calling customer service at (925) 952-2887, option 1, TTY/TDD users may call 711.