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Prior Authorization/Referral

Do I need a referral to see a specialist?

No, you do not need a referral from your primary care provider (PCP) to see a specialist. You do not need a referral for routine vision care or mental health/counseling services.

Prior Authorization

Some covered services or medicines may need approval from Coordinated Care ahead of time. This is called prior authorization (PA). Your provider may need to request a prior authorization from Coordinated Care for services or medicine to be approved. For more PA information or other support, please call 1-877-644-4613 (TTY: 711).

Click on the links below to view or download a list of Coordinated Care’s Apple Health (Medicaid) member benefits.

Services Requiring Prior Authorization

Below is a list of services that require prior authorization from Coordinated Care. Your healthcare provider should ask for PA before starting treatment.

Note: This is only a guide. Benefits, coverage and interpretation of benefits and coverage are subject to change. A member may appeal all excluded or non-covered services.

Services that require a Prior Authorization

Prior Authorization required for some or all of the services?
Ambulatory Surgery CenterSome services require prior authorization
Bariatric Surgery (Certain restrictions and limitations may apply)Some services require prior authorization.
Breast PumpsSome items require prior authorization
Cardiac RehabilitationSome services require prior authorization
ChemotherapySome services require prior authorization
Diabetic SuppliesSome items require prior authorization
Durable Medical Equipment (DME)Some items require prior authorization
High-Cost RadiologyYes
Home Health Care ServicesYes
Hospice CareSome services require prior authorization
Hospital Services InpatientYes
Hospital Services OutpatientSome services require prior authorization
Incontinence SuppliesSome items require prior authorization
Laboratory ServicesSome items require prior authorization
Mammograms (screening) for members 39 and youngerYes
Oxygen and Respiratory ServicesSome items require prior authorization
Pain ManagementSome services require prior authorization
Pharmacy ServicesSome items require prior authorization
Prenatal Genetic TestingYes
Private Duty Nursing  (PDN) Ages 0-17 onlyYes
Prosthetic and Orthotic (P&O) DevicesYes
Skilled Nursing FacilityYes
Substance Use Disorder (SUD) Treatment ServicesSome services require prior authorization
Therapy (OT, PT, ST) Services (Outpatient)Some services require prior authorization
Transhealth ServicesSome services require prior authorization
Transplant ServicesYes

Language Assistance

You are entitled to language access services when you attend a health care appointment covered by Apple Health. Let your health care provider know if you need an interpreter when you schedule your appointment.

If you need something translated into a language other than English, please call Coordinated Care. We can also provide materials in another format or auxiliary aids, like Braille, at no cost to you.