Referrals & Prior Authorization
You can get many services without a referral from your Primary Medical Provider (PMP). This means that your PMP does not need to arrange or approve these services for you. You can search for participating health partners using the Find a Doctor/Provide 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
Other services like lab tests, x-rays or physical therapy need a referral. That means you must get an OK from your PMP before you can get the service. The PMP 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
Your doctor 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 PMP or most specialists. You don’t need one for routine lab work, x-rays or many outpatient services either. Your doctor will tell you when you need these types of care.
Services that Require a Referral and Prior Authorization
A few services require both a referral from your PMP and prior authorization from CareSource. This means that your PMP has to OK the service and get an OK from CareSource too.
You can learn more by reading your member handbook.
Services Outside of Network
Call your PMP, 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.
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 PMP. 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.
Member Services: 1-844-607-2829 (TTY: 1-800-743-3333), 8 a.m. to 8 p.m., Monday – Friday