Referrals & Prior Authorization
A prior authorization is needed for a service or medication that requires approval from CareSource. If a service needs a PA, your health care provider will ask CareSource. Once the PA is approved, your provider may set up your visits for you.
CareSource will not cover certain services or medications without a PA. You can see these on the charts on the next pages. A service you are seeking may not be listed in the chart. Please call Member Services to ask if it is covered.
Examples of benefits that may need a prior authorization:
- Prescription medications
- Dental care (in hospitals and ambulatory surgery centers)
- Hospital care
- Medical supplies and equipment
- Inpatient services (mental health or Substance Use Disorder services)
- Rehabilitation services
The examples above are not complete lists of covered services for prior authorization. There may also be differences between the Healthy Indiana Plan and Hoosier Healthwise for prior authorizations requirements.
More details are in the HHW and HIP Summary of Benefits sections. Questions about PA? Call Member Services, or visit www.caresource.com/IN.
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 Outside of Network
Please call Member Services if you are not able to get the care you need from an in-network provider. CareSource may work with an out-of-network provider to meet your needs.
Continuity of Care
CareSource will work with the health care providers you are already seeing if you are a new member. We want to make sure that you keep getting the care you need. We are here to help you get regular care. If you want to know more about continuity of care, call Member Services.
Member Services at 1-844-607-2829 (TTY: 1-800-743-3333 or 711) Monday through Friday from 8 a.m. to 8 p.m., Eastern Time.