Patient Referral

THIPA Referral Policies

THIPA prides itself on its referral process. Most of our referrals are "Direct." This means that your primary care provider can make a referral to many of our specialists and no review is necessary. You can often leave the PCP office with the referral and an appointment to the specialist.

Our Utilization Management department only reviews requests that require benefit verification or requests for medical treatments for which the health plans have specific policies.

THIPA's utilization decision-making is based only on well-documented and accepted medical criteria and the medical appropriateness of care and services. No provider or any other individual, including the medical director or the utilization management staff, conducting utilization review receive any financial incentive for issuing denials of coverage or service. THIPA has no financial incentives that would encourage under-utilization of medical services. Criteria used in making a referral decision can be requested by contacting our Member Services department.

THIPA’s Self-Referral Benefit

THIPA is affiliated with the following Health Plans:

Commercial Plans: Aetna, Blue Cross, Blue Shield, CIGNA, Health Net, Great West, and PacifiCare. Senior Plans: Aetna, Blue Cross, Blue Shield, Care 1st , Health Net, MD Care, and Secure Horizons.

As long as you have a commercial (HMO) or senior plan from any of these insurances, and are a member of THIPA, you can receive the THIPA Self-Referral Benefit.

With THIPA’s Self-Referral Benefit, you don’t need an authorization and you may call to make an appointment with one of THIPA’s providers in the following specialties: Cardiology, Dermatology, Gastoenterology, OB & Gynecology, Orthopedic Surgery, Podiatry, Pulmonology, Rheumatology, and Urology. For all other specialties, you will still need to get a referral from your THIPA PCP or specialist. Click here to see a list of participating physicians in our self-referral program. Just pick up the phone and call any of them to make an appointment.

THIPA Self-Referral is a program offered to you in addition to your already existing benefits. It does not change any benefits you already have. Since this benefit is exclusive to THIPA, you may only see specialists within THIPA’s network. However, with over 250 specialists located throughout the South Bay, you are sure to find a doctor who will fit your needs.

This is an exclusive benefit that THIPA provides to both our commercial and our senior members. There are no additional premiums, no additional deductibles, and no additional copayments to use this benefit.