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 participating health partners using the Find a Doctor/Provider tool and schedule an appointment yourself. You can also check your provider directory for a list of participating health partners who offer these services. 

Services that Require a Referral

Some services and tests 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

Prior Authorization

Your PCP will assist you in getting a prior authorization from us for services that need one. For example, some procedures and most inpatient hospital stays require prior authorization.

Many other 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 PCP will tell you when you need these types of care.

You can download the (Navigate2019  |  Navigate2020) Marketplace Prior Authorization List here.

Services Outside of Network

Call 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.

Continuity of Care

We are here to help you continue and coordinate medically necessary care when you join CareSource. If you have health care services that were scheduled before you joined our plan, call us right away. Call us if you have a health condition that we need to be aware of so we can ensure a smooth transition; for example, if you need surgery or are pregnant. We want to help you get the care you need.

Member Services: 1-877-806-9284 (TTY: 711), 7 a.m. to 7 p.m., Monday – Friday


DISCLAIMERS

CareSource is a Qualified Health Plan issuer in the Health Insurance Marketplace. This is not a Health Insurance Marketplace website. This website does not display all available Marketplace plans. To see all available Qualified Health Plan options available, go to www.healthcare.gov.

This website is subject to change at any time without prior notice. This website is intended only as general information and is not an offer or invitation to contract.

This is a solicitation for health insurance. CareSource Marketplace plans have exclusions, limitations, reductions and terms under which the policy may be continued in force or discontinued. Premiums, deductibles, coinsurance and copays may vary based upon individual circumstances and plan selection. Benefits and costs vary based upon plan selection. Not all plans and products offered by CareSource cover the same services and benefits. Covered services and benefits may vary for each plan. For costs and complete details of coverage, please review CareSource’s Evidence of Coverages and Schedules of Benefits documents at www.caresource.com/marketplace.

Specific policy benefits listed on this website are intended to be a summary of coverage and do not list or describe all the benefits covered under specific policies nor is every limitation, exclusion or reduction of benefits listed. The overview of benefits, coverage and member cost shares are based on benefits being received from an in-network provider. To be eligible for reimbursement, all health care services must be provided by an in-network provider, except when applicable federal and state law or the applicable Evidence of Coverage for each policy provide otherwise.

Rates, benefits, premiums, deductibles, co-payments, co-insurance, and out of pocket expenses may vary based upon a variety of factors, including but not limited to, age, county of residence, smoking status, and level of policy selected.

References to CareSource pertain to each individual company or other CareSource affiliated companies, such as CareSource, CareSource Kentucky Co., CareSource Indiana Inc., CareSource West Virginia Co., and CareSource Georgia, Co. Each company is a separate entity and is not responsible for another’s financial condition or contractual obligations.

CareSource does not discriminate on the basis of race, color, national origin, disability, age, sex, gender identity, sexual orientation, or health status in the administration of the plan, including enrollment and benefit determinations.

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Last updated 10/23/2019