Referral requirement for specialty services

To help us make sure you get the care you need, we need a primary care provider (PCP) referral for certain specialty services for some members. A referral is notification from a PCP to us that you can get care from a different provider. The referral helps PCPs better guide the care and services you get from the doctors you see, so that you get the best care and stay as healthy as possible.

If you're part of this program, your PCP will need to get a referral for:

  • Professional services, like a visit to a specialist (health care providers with special training who focus on one part of the body)
  • Outpatient hospital visits
  • Surgical day care
  • Your first visit or evaluation for:
    • Speech therapy
    • Occupational therapy
    • Physical therapy

If your PCP needs to give a referral for these services, your Member ID card will say "PCP Referral Required." Doctors should not bill you for any of these services if you get them from an in-network provider, but it's still a good idea to make sure you have a referral for these services if you're part of this program.

PCP referrals aren't required for any outpatient behavioral health (mental health and/or substance abuse), Obstetrics/Gynecological (OB/GYN), or family planning services. If you're part of this program, you should ask your PCP about referrals before an appointment with anyone besides your PCP, behavioral health specialist, OB/GYN, or family planning provider.

If you don’t want to be part of this new program, you can change your PCP at any time to a different PCP in our provider network who is not part of this program. If you have questions or want to change PCPs, call us at 888.257.1985 (TTY: 711), Monday through Friday, 8 a.m. to 5 p.m. We're happy to help.

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