Referrals

Self-referrals

Self-referrals are services you can arrange for yourself without first calling your primary care practitioner (PCP). You must see a Keystone First network provider for these self-referred services. Services that do not need a referral or prior authorization are:

  • Prenatal visits.
  • Routine obstetric (OB) care.
  • Routine gynecological (GYN) care.
  • Routine mammograms, with a prescription.
  • Routine family planning services. **
  • Routine dental services.
  • Routine eye exams.*
  • Prescription eyeglasses for members under age 21.
  • Tobacco cessation counseling sessions.**
  • First visit with a chiropractor.
  • First 24 visits for outpatient physical, occupational, and speech therapy.
  • Emergency services.**
  • DME purchases costing less than $750 that are covered by the Medical Assistance program and with a prescription (see the prior authorization).

* You may need to get a referral or prior authorization from your PCP for some specialty care services. There may also be some limitations for self-referrals. If you are not sure if you need a referral from your PCP for a service, ask your PCP or call Member Services.

** This self-referred service may be provided by a provider not in the Keystone First network.

PCP referrals

When your PCP thinks you need to see a specialist, he or she will refer you to a specialist who can best help you with your health care needs. To see the specialist, your PCP may need to send a referral form to that specialist. Or your PCP may need to give you a prescription to see the specialist. Ask your PCP if you will need a referral form or a prescription.

There are some specialist services you can get without seeing your PCP first. These specialists do not need a referral form or a prescription. Please see the section about self-referrals to find out which specialists you can go to without seeing your PCP first.

In some cases, members with a life-threatening, degenerative, or disabling disease or condition, or members with other special needs may be able to have a “standing referral.” A standing referral means you do not have to see your PCP each time you need to see a specialist. Call Member Services for more information.

 

Members