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 Center | Some services require prior authorization |
| Bariatric Surgery (Certain restrictions and limitations may apply) | Some services require prior authorization. |
| Breast Pumps | Some items require prior authorization |
| Cardiac Rehabilitation | Some services require prior authorization |
| Chemotherapy | Some services require prior authorization |
| Diabetic Supplies | Some items require prior authorization |
| Durable Medical Equipment (DME) | Some items require prior authorization |
| High-Cost Radiology | Yes |
| Home Health Care Services | Yes |
| Hospice Care | Some services require prior authorization |
| Hospital Services Inpatient | Yes |
| Hospital Services Outpatient | Some services require prior authorization |
| Incontinence Supplies | Some items require prior authorization |
| Laboratory Services | Some items require prior authorization |
| Mammograms (screening) for members 39 and younger | Yes |
| Oxygen and Respiratory Services | Some items require prior authorization |
| Pain Management | Some services require prior authorization |
| Pharmacy Services | Some items require prior authorization |
| Prenatal Genetic Testing | Yes |
| Private Duty Nursing (PDN) Ages 0-17 only | Yes |
| Prosthetic and Orthotic (P&O) Devices | Yes |
| Skilled Nursing Facility | Yes |
| Substance Use Disorder (SUD) Treatment Services | Some services require prior authorization |
| Therapy (OT, PT, ST) Services (Outpatient) | Some services require prior authorization |
| Transhealth Services | Some services require prior authorization |
| Transplant Services | Yes |
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.
HCA38577/CS035