Referral Needed

The following services require a referral from your PCP. This means that your PCP will recommend or request these services for you before you can get them. Your PCP will either call and arrange these services for you, give you written approval to take with you when you get the referred services, or just tell you what to do. In some cases, CareSource may authorize a specialist to make referrals for you.

  • Diagnostic services (X-ray, lab) - Participating specialists may also send you for diagnostic tests. Some may require authorization.
  • Specialist services - This includes visits to participating specialists not listed in the previous section, such as a dermatologist. Participating specialists are listed in the Provider Directory.
  • Outpatient hospital services
  • Physical and occupational therapy - You may have up to 30 visits per year without a Prior Authorization.
  • Renal dialysis (kidney disease)

Referral and Prior Authorization needed

The following services require a referral from your PCP and prior authorization from CareSource before you can get them. Your PCP will ask for a prior authorization from us then schedule these services for you. If you are seeing a specialist, he/she will get approval from your PCP then your appointment or services will be scheduled.

  • Some home health services
  • In-patient hospital services - Emergency services do not require a referral or prior authorization. Semi-private room and board is included.
  • Nursing facility services for a short-term rehabilitative stay
  • Hospice care (care for terminally ill, e.g., cancer patients)
  • Some durable medical equipment, including hearing aids
  • Orthotics/prosthetics
  • Ambulance and ambulette transportation - Emergencies do not require a referral or prior authorization
  • Some pain management services
  • Services from an out-of-network provider