Referrals & Prior Authorization
HAP CareSource covers all medically necessary Medicaid-covered services at no cost to you. Medically necessary means you need the services to prevent, diagnose, or treat a medical condition. Some of these services may require a referral from a provider. A referral is when a provider recommends or requests services or care from a specialist for you. Your provider 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.
Sometimes, you may need care or a type of service that requires a prior authorization. Prior authorization is how we decide if a service will be covered by HAP CareSource. HAP CareSource must review and approve these services before you get them. For example, some procedures and most hospital stays will need prior authorization. As a member of HAP CareSource, you do not need to ask for the prior authorization from us. Your provider will request this approval for you.
We have a full list of services that require prior authorization for you to view. There is a 30-calendar day advance notice if there are any changes to this list. Please call Member Services if you have any questions or would like a printed copy of any of the changes to the prior authorization list.
Please Note:
- You must get services from facilities and/or providers in the HAP CareSource network. Network or in-network provider refers to the providers who accept HAP CareSource insurance and see patients who are covered through HAP CareSource.
- When you see a provider who is not in the HAP CareSource network, 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 HAP CareSource network.
- Please check the Prior Authorization List prior to your request as changes may occur throughout the year.
Member Services: 1-833-230-2053 (TTY: 711), 24 hours a day, seven days a week.