Referrals and Authorizations
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
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 this 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.