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Referrals for Managed Care Members

  • Who: The following specialties require a referral for Medicare products. These specialties require referrals regardless of the place of service. Please note that Commercial HMO and POS and Safety Net products no longer require physician to physician referrals.
  • How it Works: See ‘Who Can Request’ below for rules on who can generate or update a referral. Treating providers must obtain a referral number before providing services.

Some member contracts may have other restrictions. Not all contracts include all benefits. Payment is based on member contract benefits, eligibility and medical necessity at the time of service. The provider delivering the service is responsible for ensuring that the required Referral has been obtained. Please verify the member referral requirements at the time you verify benefits.

Claims will process according to the member’s benefit plan on the date of service. Failure to obtain the necessary referral(s) may result in the denial of the claim or reduced payment allowance.

* For some member contracts, Occupational, Physical and Speech Therapy require Preauthorization not a Referral. Please refer to our Clinical Review Preauthorization list.

Medical Specialty Medicare HMO Commercial HMO/POS Safety Net
Allergy and Immunology Required Not Required Not Required
Cardiology Required Not Required Not Required
Chiropractor Required Not Required Not Required
Dermatology Required Not Required Not Required
Endocrinology Required Not Required Not Required
Gastroenterology Required Not Required Not Required
Group Therapy Not Required Not Required Not Required
Neuro-Psychiatry Required Not Required Not Required
Nutritional Counseling Required Not Required Not Required
Occupational Medicine Required Not Required Not Required
Occupational Therapy Preauthorization Required * Preauthorization Required * Preauthorization Required *
Oral Surgery Required Not Required Not Required
Orthopedics (with or w/o surgery) Required Not Required Not Required
Otolaryngology Required Not Required Not Required
Pain Management Required Not Required Not Required
Pediatric Development Not Required Not Required Not Required
Physical Therapy Preauthorization Required * Preauthorization Required * Preauthorization Required *
Plastic Surgery Required Not Required Not Required
Podiatry (with or w/out surgery) Required Not Required Not Required
Reproductive Endocrinology Required Not Required Not Required
Speech Pathology or Therapy Preauthorization Required * Preauthorization Required * Preauthorization Required *
Substance Abuse Not Required Not Required Not Required for Child Health Plus and Family Health Plus only.
Medicaid managed case service via standard Medicaid.
Urology Required Not Required Not Required

To Request or Update a Referral
Request Online with Clear Coverage, or call Referral Intake at 1-800-363-4658

If you are a Servicing Provider you can use this link to check referrals.

Who Can Request or Update?

The Following Providers... Can Request or Update a Referral for...
Primary Care Providers (PCPs) (who are on-file with the Plan as the patient’s PCP)
  • Care to any participating provider for all covered services
  • DEXA scans
All Providers
  • Diagnostic testing (some tests may require Preauthorization
  • Physical, occupational, hand or speech therapy
  • Dietary consultations
  • Care by another participating provider of same specialty if unable to treat the patient
Allergy, Immunology, Rheumatology
  • DEXA scans
Cardiologists
  • Cardiac catheterization or angioplasty (if he/she has a valid referral for related diagnosis)
  • Care by a cardiothoracic surgeon
  • Cardiac rehabilitation
Cardiothoracic Surgeons
  • Cardiac rehabilitation
Endocrinologists
  • DEXA scans
Gynecologists/ Obstetricians (who are on-file with the Plan as the patient’s PCP or alternate PCP)
  • Any care
  • Infertility care for a patient’s husband, if he is a covered member on the policy
Neurologists/Neurosurgeons
  • Sleep studies
  • Neuropsychological testing
  • Pain treatment
  • Physical, occupational or speech therapy
Oncologists
  • Care by a participating specialist for related diagnoses
Orthopedists
  • Care by a participating specialist for related diagnoses
  • Emergency fracture care or dislocations
  • Follow-up care to emergency treatment, regardless of diagnosis
  • Neurologists or neurosurgeons
  • Pain treatment
  • Physical or occupational therapy (if he/she has a valid referral for related diagnosis)
Otolaryngologists
  • Sleep studies
  • Care by an audiologist for hearing loss (if he/she has a valid referral for related diagnosis)
  • Speech therapy (if he/she has a valid referral for related diagnosis)
Physical Medicine & Rehabilitation
  • Neuropsychological testing
Psychiatrists
  • Follow-up care to an emergency hospital admission
  • Care by another behavioral health provider
  • Neuropsychological testing
Psychologists
  • Care by another behavioral health provider
  • Neuropsychological testing
Pulmonologists
  • Sleep studies
Certified Social Workers
  • Care by another behavioral health provider
  • Neuropsychological testing