Referrals & Prior Authorization
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 CareSource. 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 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.
- You must get services from facilities and/or providers in the CareSource network. Network or in-network provider refers to the providers who accept CareSource insurance and see patients who are covered through CareSource.
- When you see a provider who is not in the 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 CareSource network.
- Please check the Prior Authorization List prior to your request as changes may occur throughout the year.
Member Services: 1-800-488-0134 (TTY: 1-800-750-0750 or 711), Monday – Friday 7 a.m. – 8 p.m.