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 providers in the CareSource network using the Find a Doctor/Provider tool and schedule an appointment yourself. You can also check your provider directory for a list of in-network providers who offer these services.

Please Note:

  • You must get services from facilities and/or providers in the CareSource network.
  • When you see a provider who is not in the CareSource network, Navigateprior 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 CareSource network.
  • Please check the NavigatePrior Authorization List prior to your request as changes may occur throughout the year.

Helpful Terms to Know

  • Network Provider or In-Network Provider – A doctor, hospital, drugstore, or other licensed health care provider that has signed a contract agreeing to give services to CareSource members. These providers accept CareSource insurance and see patients who are covered through CareSource. They are listed in our Provider Directory and on our website.
  • Out-of-Network Provider – A doctor, hospital, drugstore, or other licensed health care provider that has not signed a contract agreeing to give services to CareSource members. CareSource will not pay for services from these providers unless it is an emergency, we have given prior authorization, or you are getting family planning services.
  • Prior Authorization (PA) – This means that CareSource must review and approve the service before you receive it. Your health care provider will request the approval from CareSource. Your doctor will assist you in getting a Navigateprior authorization from us for services that need one. For example, some procedures and most inpatient hospital stays require prior authorization.
  • Referral – This means that your PCP or other health care provider will recommend or request these services for you before you can get them. Your PCP 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.

Member Services: 1-800-488-0134 (TTY: 1-800-750-0750 or 711), Monday – Friday 7 a.m. – 7 p.m.