Referrals and Authorizations

Referrals

We do not require a referral from your PCP in order to see a specialist. However, some specialists may require a referral. If that is the case, they will tell you.

For some medical services, you may need a referral from your PCP. If you need one of these services, your PCP will coordinate your care and refer you to a provider. If you would like help finding an in-network provider, please call Member Services and we’ll be happy to help.

The following are services requiring a referral from your PCP:

Diagnostic tests (X-ray & lab)
Scheduled outpatient hospital services
Planned Inpatient admission
Clinic services
Renal dialysis (kidney disease)
Out-of-network providers require Louisiana Healthcare Connections approval
Durable Medical Equipment (DME)
Home health care

Prior Authorization for Services

When you need care, always start with a call to your doctor. Some covered services may require Prior Authorization by Louisiana Healthcare Connections.

A Prior Authorization decides if a service should be covered based on:

whether the service is needed (medical necessity)
whether the service is likely to be helpful (clinical appropriateness)

Your provider will give us information (over the phone or in writing) about why you need the service. We will look to see if the service is covered and ensure it is medically necessary. We will make the decision as soon as possible based on your medical condition. Decisions are usually made within 14 calendar days. If you need to be admitted to the hospital for an urgent medical need, the decision will be made within two calendar days. If you require ongoing inpatient care, the decision will be made within one calendar day.

Your provider can tell you if a service needs a Prior Authorization. You can also call Member Services at 1-866-595-8133 (TTY: 711) to see if something needs Prior Authorization.

We will let your provider know if the service is approved or denied. If you or your provider are not happy with the decision, you can request a second review. This is called an Appeal. See the Member Satisfaction section of your Member Handbook for more information.

NOTE: Emergency Room (ER) and post stabilization services NEVER require Prior Authorization. If there are any major changes to the Prior Authorization process, we will inform our members and providers right away.

Prior Authorization for Medications

Some medications may require Prior Authorization by Magellan Medicaid Administration, Louisiana Medicaid’s Pharmacy Benefits Manager, before they are covered by your health plan. Magellan handles Prior Authorizations for all Louisiana Medicaid health plans. Your provider can tell you if a medication needs Prior Authorization. You can also call Magellan’s 24/7 Member Help Desk at 1-800-424-1664 (TTY: 711) to see if a medication needs Prior Authorization.

If Prior Authorization is needed, your provider will give Magellan information about why you need the medication. Magellan will base its decision on the Louisiana Medicaid Single PDL and the information provided by your doctor. Magellan will let your provider know if the medication is approved or denied.

If you or your provider are not happy with the decision, you can request a second review from Louisiana Healthcare Connections. This is called an appeal.