Referral Needed
The following services require a referral from your PCP. This means that your PCP 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 written approval to take with you when you get the referred services, or just tell you what to do. In some cases, CareSource may authorize a specialist to make referrals for you.
Diagnostic services (X-ray, lab) done outside of your PCP’s office
Participating specialists may also send you for diagnostic tests.
Specialist services
This includes visits to participating specialists not listed in the previous section, such as a dermatologist. Participating specialists are listed in the provider directory.
Outpatient hospital services
Physical and occupational therapy
You can make up to 30 visits per year without a prior authorization.
Renal dialysis (kidney disease)
Referral and Prior Authorization Needed
The following services require a referral from your PCP and prior authorization from CareSource before you can get them. Your PCP will ask for a prior authorization from us then schedule these services for you. If you are seeing a specialist, he/she will get approval from your PCP then your appointment or services will be scheduled.
Home health services
Nursing facility services for a short-term rehabilitative stay
Hospice care (care for terminally ill, e.g., cancer patients)
Durable medical equipment, including hearing aids
Orthotics/prosthetics
Orthodontia
Services from an out-of-network provider
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.
Ambulance and ambulette transportation
Emergencies do not require a referral or prior authorization.
Non-emergent hospital transfers