Referrals & Advance Approvals for Services

If you need certain types of covered services or supplies, you must get approval in advance through your Primary Care Physician (PCP).

When your PCP thinks you need specialized treatment, he/she will either give you a referral to see a specialist (i.e. a cardiologist for patients with heart conditions) or certain other providers in our network, or will request a prior authorization (prior approval) from the Health Plan on your behalf.

It is very important to get a referral or prior authorization (approval in advance) from your PCP for the services and items listed below that require it. If you don’t have approval in advance for services or items that require a referral or prior authorization, you may have to pay for these services yourself.

You can get services such as those listed below without getting approval in advance from your PCP:

  • Routine women’s health care, which includes breast exams, screening mammograms (x-rays of the breast), Pap tests, and pelvic exams as long as you get them from a network provider.
  • Flu shots, Hepatitis B vaccinations, and pneumonia vaccinations as long as you get them from a network provider.
  • Emergency services from network providers or from out-of-network providers.
  • Urgently needed care from in-network providers or from out-of-network providers when network providers are temporarily unavailable or inaccessible, e.g., when you are temporarily outside of the plan’s service area.
  • Kidney dialysis services that you get at a Medicare-certified dialysis facility when you are temporarily outside the plan’s service area. If possible, please call Member Services before you leave the service area so we can help arrange for you to have maintenance dialysis while you are away.
  • Dermatology (up to 5 visits per year) must be from an in-network provider.
  • Behavioral Health Services - must be from an in-network provider.

Your PCP can issue a referral for the following listed services:

  • Participating specialists - for office visit and treatments in the office that do not require prior authorization.
  • Free-standing - (not hospital-based) radiology centers for CT scans and MRIs.
  • Ambulatory Surgery Centers - except for excluded procedures that need prior authorization (see below).
  • Orthotics/Prosthetics - only orthotic/prosthetic with a purchase price less than $500.00.
  • Physical, Occupational or Speech Therapy - In free-standing office for Evaluation plus 9 visits (10 total) – home therapy or outpatient therapy and visits more than 10 require prior authorization.
  • DME - only DME with a purchase price less than $500.00 or monthly rental price less than $38.50 per month. Excludes: all wheelchairs, hospital beds, CPAPs, BiPAPs, nerve and bone growth stimulation devices and oxygen, as well as TENS devices, wound care/wound vacuums and related supplies, repairs, miscellaneous codes and all Medicare non-covered items, all of which require prior authorization.

Your PCP will need to submit an authorization request prior to the following services being rendered (Prior Authorization is required):

  • Abortions
  • Acute Rehabilitation Facility
  • Ambulatory Surgery Center for Blepharoplasty, Podiatric Surgery, Reduction Mammoplasty, Rhinoplasty, Septoplasty, Vein treatments, Ocular Surgery, Pain Management Injections, Plastic Surgery only
  • Chemotherapy
  • Clinical Trials Not Approved by Medicare
  • Cosmetic Procedures
  • Diabetic Education
  • DME > $500
  • Enteral Feedings
  • Experimental/Investigational Procedure
  • Genetic Testing
  • Home Health Services
  • Hospice ** Notification only
  • Hyperbaric Oxygen Therapy
  • Implantable pump/device or stimulator
  • Injectables/Infusion Therapy
  • Inpatient Hospital
  • Medical Nutrition Education
  • MOHS Procedure (Dermatology)
  • Non-Participating Provider
  • Obstetrical Care
  • Orthotics/Prosthetics > than $500
  • Any service in an Outpatient Hospital
  • Pain Management
  • Radiation Therapy
  • Radiology: PET, Pill or Virtual Endoscopy
  • Rehab Cardiac/Pulmonary/Respiratory
  • Rehab – any outpatient hospital and any office therapy > than 10 visits.
  • Skilled Nursing Facility
  • Sterilizations
  • TMJ Joint treatment
  • Transplant
  • Wound Care (outpatient hospital only)

For more information on your coverage and when you need to get prior authorization or a referral, please call member services toll free at 1-866-245-5360 or TTY/TDD: 711. You may also refer to the Evidence of Coverage booklet you received in the mail for additional information.

Your Plan may use Interqual® criteria to make coverage decisions. To review this criteria, click the link below. After you click the link, follow the steps on the screen to first create an account and then login to access Interqual® criteria.

Interqual® Coverage Guidelines

Your Plan may also use medical policies and clinical guidelines used by an affiliated health plan, Simply Healthcare. Click the link below to review these guidelines.

Medical Policies and Clinical Guidelines

Last updated 01/12/2024