Make a Referral
CareSource uses a paperless referral system to make it easy for PCPs to refer their patients to participating CareSource specialists. PCPs may only refer members to another provider who also participates with CareSource unless special circumstances exist, in which case prior authorization is needed.
Please follow these steps to make a referral:
PCP: Document the referral in the patient’s medical chart. No forms or referral numbers are required. However, you must notify the specialist of your referral.
Specialist: Document in the patient’s chart that the patient was referred to you for services. Referral numbers are not required on claims submitted for referred services. Generally, only PCPs can issue referrals to additional specialists and specialist-to-specialist referrals are not allowed. However, in some cases, specialists may provide services or make referrals in the same manner as a PCP.
Document in the medical record the number of visits or length of time of each referral. Medical records may be subject to random audits to ensure compliance with this referral procedure.
Standing referrals
A PCP may request a standing referral to a specialist for a member with a condition or disease that requires specialized medical care over a prolonged period of time. The specialist may provide services in the same manner as the PCP for chronic or prolonged care. The period of time must be at least one year to be considered a standing referral.
Members who meet the definition of Children with Special Health Care Needs may access specialty care providers directly through the use of a standing referral. Members are instructed to obtain the standing referral from their PCP. Children with Special Health Care Needs are patients between 6 months and 21 years of age who have asthma, HIV/AIDS, teen pregnancy, a letter of approval from the Bureau of Children with Medical Handicaps, or are receiving Supplemental Security Income (SSI) for a chronic medical condition.
Referrals to out-of-plan providers
A member may be referred to an out-of-plan provider if:
Referrals for second opinions
A second opinion is not required for surgery or other medical services, however, health care providers or members may request a second opinion at no cost to the member. The following criteria should be used when selecting a provider for a second opinion:
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The provider must be a participating provider, if possible. If not, a prior authorization must be obtained to send the patient to a nonparticipating provider.
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The provider must not be affiliated with the member’s PCP or the specialist practice group from which the first opinion was obtained.
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The provider must be in an appropriate specialty area.
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Results of laboratory tests and other diagnostic procedures must be made available to the provider giving the second opinion.