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How to Get Covered Services

Call your PCP when you need regular care. He or she will send you to see a specialist for tests, specialty care and other covered services that he or she doesn’t provide. Be sure your PCP approves you to see a specialist. If your PCP does not provide an approved service, ask him or her how you can get it.

Understanding Referrals and Prior Authorizations

Referrals

You may see any doctor in our network without a referral. However, some doctors may request a referral from your PCP. We will still cover medically necessary services provided by an in-network provider without a referral.

You may be referred to another provider if:

  • Your PCP does not provide the care or service you need
  • You need to see a specialist

You could be referred for medical tests, treatments or other services.

Referrals for certain care or services do not require our approval. These include:

  • Routine diagnostic tests
  • Lab tests
  • Basic X-ray services
  • Some routine care provided in a doctor’s office (not in a hospital)

Prior Authorizations (PAs)

Sometimes, your PCP or another provider may need to ask us to approve care before you get a service. This is called prior authorization (or PA for short). Your PCP or provider will contact us for this approval.

A PA is needed for these types of services:

  • Rented or purchased medical supplies and equipment that costs more than $250
  • Some medical tests done by your PCP or provider
  • Cardiac and pulmonary rehabilitation programs
  • Home health care
  • Therapies (physical, occupational, speech)
  • Inpatient and residential behavioral health services

This is not a complete list, and it may change from time to time. See your member handbook for a current list of services that require a PA.

If we do not approve a PA request, we’ll let you know. If we do not approve a PA request, and you still receive the service, the provider cannot bill you unless you agreed to pay for it in writing. If a PA is denied, you can ask for an appeal. If you still are not happy once the appeal is complete, you can ask for a State Fair Hearing. See your member handbook for more information.

Type of Request Decision Time Frame Who Can Request One

Prior Authorization “How To”

Type of Request

Decision Time Frame

Who Can Request One

Standard (for non-emergency care)

2 business days*

Your provider

Expedited/Fast** (for urgent care)

24 hours**

Your provider

*Sometimes we may need more time to make a standard decision. This may be because we need more information and it’s in your best interest. If so, we’ll take up to 14 more business days.

**Sometimes we may need more time to make a fast decision. If so, we’ll take up to 48 more hours.

Please note: PA decisions for services that have already been provided are made within 30 calendar days of us getting all needed information.

Services Available Without Authorization

You don’t need approval from us or your PCP for the following services:

  • Direct access to in-network women’s health specialists for routine and preventive health care services
  • Emergency/urgent care
  •  Family planning (any health plan provider)
  • Well-child visits for children age 20 or younger
  • Routine vision care
  • One women’s health visit to an OB/GYN provider each year
  • Post-stabilization services
  • Visits to your PCP
  • Most outpatient behavioral health services (in-network)

Even though you don’t need approval for these services, you will need to see a provider in our network.

You can find a provider using our online provider search tool – Find a Provider. When you’ve made your choice, call to set up an appointment. Remember to take your ID cards with you.

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Last Updated On: 6/22/2018