Referrals & Prior Authorization

You can get many services without a referral from your primary care provider (PCP). This means that your PCP does not need to arrange or approve these services for you. You can search for participating health partners using the "Find a Provider" tool. You can also request a provider directory for participating health partners who offer these services. 

Services that Require a Referral

Other services like lab tests, X-rays or physical therapy need a referral. That means you must get an OK from your PCP or in-plan specialist before you can get the service. The PCP or in-plan specialist will do one of the following:

• Arrange the services for you
• Tell you how to get the service
• Get an approval from your insurance company (that you will receive a copy of by mail)

Prior Authorization

Your doctor will assist you in getting a prior authorization from us for services that need one. For example, some procedures and most inpatient hospital stays require prior authorization.

Many other services do not need a prior authorization. You do not need one to see your PCP or in-plan specialists. You don’t need one for routine lab work, X-rays or many outpatient services either. Your doctor will tell you when you need these types of care.

Services that Require a Referral and Prior Authorization

A few services require both a referral from your PCP and prior authorization from The Health Plan. This means that your PCP has to OK the service and get an OK from The Health Plan, too.

You can learn more by reading your member handbook.

Services Outside of Network

Call your PCP, other in-network provider or us to find out if you need an OK to go have services from a provider who is not in your network. The Health Plan may authorize and pay for out-of-network care if the service is medically necessary and the service from an in-network provider is not available.

Continuity of Care

We are here to help you continue and coordinate medically necessary care when you join The Health Plan. If you have health care services that were scheduled before you joined our plan or approved by Medicaid Fee-for-Service call us right away. Call us if you have a health condition that we need to be aware of so we can ensure a smooth transition; for example, if you need surgery or are pregnant. We want to help you get the care you need.