Referrals and Authorizations

When do I need a Referral?

Your PCP will help you know when you need to see a specialist and give you a referral. A referral is a written note given to you by your PCP to see a different doctor. You must get a referral to see a doctor other than your PCP except for well-women visits, family planning, and some mental health services. If you want to see a specialist, but CareFirst CHPDC said it wouldn’t pay for the visit, you can:

• Make an Appointment with another doctor in the CareFirst CHPDC network and get a second opinion
• Appeal our decision
• Ask for a Fair Hearing

Self-Referral Services

There are certain services you can get without getting prior permission from your PCP. These are called self-referral services and are listed below.

You DO NOT need a Referral to:

• See your PCP
• Get care when you have an emergency
• Receive services from your OB/GYN doctor in your network for routine or preventive services (females only)
• Receive Family Planning Services
• Receive services for sexually transmitted diseases (STDs)
• Receive Immunizations (shots)
• Visit a vision provider in the network
• Take your child to a dental provider in the network
• Receive emergency mental health or services for problems with alcohol or other drugs
• Receive up to 10 mental health sessions (A treatment plan is required after 10 visits.)

When do I need an Authorization?

The majority of services offered by CareFirst CHPDC do not require a Prior Authorization. Prior authorization (or prior approval) means approval for a health service that is not routinely covered by CareFirst CHPDC. You must get this approval before you receive the service. Wellness care and diagnostic services (such as screenings and labs) require no prior plan notification. Services that do require a Prior Authorization are consistent with other plans. Call Enrollee Services at (202) 821-1100 to ask about getting a prior authorization. These services include, but are not limited to:

• Inpatient and Outpatient Services
• Rehabilitative Services
• Nursing Home/ Skilled Nursing/Hospice Care
• Major Surgery and General Anesthesia
• Out of Network Providers
• Non Formulary Medications

Out of Network Providers

CareFirst CHPDCwill pay for the care you get when you go to one of our doctors or other health care providers. We call these doctors and other health care providers our “network” providers. All these “In-Network” doctors can be found in your Provider Directory. A doctor or provider who is not one of ours is called an “Out-of-Network” Provider.

• If you go to an “Out-of-Network” doctor, hospital or lab, you may have to pay for the care you get. You will not have to pay if you have asked us first and we have told you, usually in writing, that it is okay. We call this “prior written authorization.”

Emergency Services

You may go to an Emergency Room which is out-of–network even if you do not have prior authorization

Non-Formulary Medications

If you and/or your provider believe that you need a medication not on the CareFirst CHPDC Formulary, you may start the exception request process.

Family Planning Authorizations

You may go to a Family Planning provider who is out-of–network even if you do not have prior authorization.