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.
Use the Find a Doctor/Provider tool to find doctors or health partners that offer these services and schedule an appointment. You can also check your provider directory.
Services that Require a Referral
Sometimes you will need an OK from your doctor or from Humana – CareSource® to see another doctor. Your primary care provider (PCP) will recommend or request these services for you before you can get them:
- Diagnostic services (X-ray, lab) done outside of your PCP’s office – Participating specialists may also send you for diagnostic tests. Some may require prior authorization.
- Specialist services – This includes visits to a cardiologist or dermatologist, to name a few. Use our Find a Doctor/Provider tool to find participating specialists.
- Outpatient hospital services
- Physical and occupational therapy – You can make up to 20 visits per year without prior authorization. Members under 21 years of age may have more visits if medically necessary as part of Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services. Prior authorization may be required.
- Renal dialysis (kidney disease)
Your 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
In some cases, Humana – CareSource may authorize a specialist to make referrals for you.
Services that Require a Referral and Prior Authorization
There could also be times when both a referral from your PCP and prior authorization from Humana – CareSource are needed before you can get a service. Your PCP will ask for a prior authorization from us. Then he or she will schedule these services for you. If you are seeing a specialist, he/she will get approval from your PCP. After that, your appointment or services will be scheduled.
Here are few examples:
- Some home health services
- 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
- Orthodontia (covered only for members under the age of 21 with an approved prior authorization)
- Developmental therapy services for children aged birth to six years
- Ambulance and ambulette transportation – Emergencies do not require a referral or prior authorization.
- Some pain management services
- Services from an out-of-network provider
You can learn about covered medications by clicking My Pharmacy.
Member Services: 1-855-852-7005 (TTY: 1-800-648-6056 or 711), 7 a.m. – 7 p.m., Monday – Friday