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) done outside of your PCP's office - Participating specialists may also send you for diagnostic tests.
  • 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 can make up to 30 visits per year without a Prior Authorization.
  • Renal dialysis (kidney disease)

Referral and Prior Authorization needed

  • Some home health services
  • Abortions
  • In-patient hospital services (including lab and X-ray) - Emergency admissions 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
  • Orthodontia and some dental services including dentures
  • Some radiology services including CT scans, MRIs and PET scans
  • Ambulance and ambulette transportation - Emergencies do not require a referral or Prior Authorization.
  • Cosmetic or plastic surgery
  • HealthChek services beyond covered benefits
  • Services from an out-of-network Provider