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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

When you need care, always start with a call to your doctor. Some covered services, including medications, may require prior authorization by Louisiana Healthcare Connections. Prior authorization means approval needed before a service is provided or approval needed to continue a service.

Services Requiring Prior Authorization

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

In most cases, the following services must be approved before you get them:

  • Advanced radiology
  • Durable medical equipment (DME) rentals and purchases
  • Elective inpatient procedures
  • Genetic testing
  • Home health services
  • Inpatient admissions
  • Inpatient rehabilitation facility admissions
  • Long-term acute care hospital admissions
  • Outpatient therapy services
  • Pain management services
  • Pharmacy injectables
  • Select outpatient procedures
  • Skilled nursing facility admissions
  • Home location services

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. For medications and other pharmacy services, the decision will be made within 24 hours.

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.

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. For more information on appeals, visit our appeals webpage.

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.