Referrals & Prior Authorization

You can get many services without a referral from your Primary Care Provider (PCP). This means that your PCP does not need to arrange or approve these services for you. You can search for providers in the CareSource network using the Find a Doctor/Provider tool and schedule an appointment yourself. You can also check your provider directory for a list of providers in the CareSource network who offer these services.

Your doctor will help you get a Navigate prior authorization from us for services that need one. Many services do not need a prior authorization. You do not need one to see your PCP or most specialists. You don’t need one for routine lab work, x-rays or many outpatient services either. Your provider will tell you when you need these types of care.

Please Note:

  • You must get services from facilities and/or providers in the CareSource network.
  • When you see a provider who is not in the CareSource network, Navigate prior authorization is required except in emergency situations. You do not need a prior authorization for any office visit or procedure done at provider offices (PCP or specialty provider) in the CareSource network.
  • Please check the prior authorization list prior to your request as changes may occur throughout the year.
  • Please note the difference between a referral and a prior authorization.

Services that Require a Referral

Other services like lab tests, x-rays or physical therapy need a referral. That means you must get an OK from your PCP before you can get the service. The PCP will do one of the following:

  • Arrange the services for you
  • Give you a written OK to take with you when you get the service
  • Tell you how to get the service

Services that Require a Referral and Prior Authorization

A few services require both a referral from your PCP and prior authorization from CareSource. This means that your PCP has to OK the service and get an OK from CareSource, too. An example is a planned hospital procedure.

You can learn more by reading your Navigate member handbook.

Services Outside of Network

Call your PCP, other in-network provider or us to find out if you need an OK to go have services from a provider who is not in your network. CareSource may authorize and pay for out-of-network care if the service is medically necessary and the service from an in-network provider is not available.

Standing Referral

CareSource allows members with special needs who need ongoing treatment or regular monitoring to see a specialist for treatment through a standing referral from your PCP. The treatment given by the specialist must be right for your health issue and needs.

Continuity of Care

We are here to help you continue and coordinate medically necessary care when you join CareSource. If you need to know if continuity of care is for you, please call Member Services.

Helpful Terms to Know

  • Network Provider or In-Network Provider – A doctor, hospital, drugstore, or other licensed health care provider that has signed a contract agreeing to give services to CareSource members. These providers accept CareSource insurance and see patients who are covered through CareSource. They are listed in our Provider Directory and on our website.
  • Out-of-Network Provider – A doctor, hospital, drugstore, or other licensed health care provider that has not signed a contract agreeing to give services to CareSource members. CareSource will not pay for services from these providers unless it is an emergency, we have given prior authorization, or you are getting family planning services.
  • Prior Authorization (PA) – This means that CareSource must review and approve the service before you receive it. Your health care provider will request the approval from CareSource. Your doctor will assist you in getting a Navigate prior authorization from us for services that need one. For example, some procedures and most inpatient hospital stays require prior authorization.
  • Referral – This means that your PCP or other health care provider 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 a written approval to take with you to the referred services, or tell you what to do.

Member Services: 1-855-202-0729 (TTY: 1-800-255-0056 or 711), Monday – Friday 7 a.m. – 7 p.m.