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    PA and referrals

    There are times when you may need care from a specialist. Your primary care physician (PCP) will coordinate referrals for you, when needed. Some covered medical services may also need prior authorization (PA). This is an approval that happens beforehand. It’s for special services your PCP or specialist want you to have. 

    PA

    PA

    Some medical services and supplies need PA — approval for coverage from your health plan first, like:

    • Certain acute outpatient services
    • Planned hospital stays

    This means your providers or specialists need permission to provide certain services first. They’ll know how to do this. And we’ll work together to make sure the service is what you need. You can find out which services need PA in 3 ways:

    • Check your Evidence of Coverage to learn more about services that need PA:

    Evidence of Coverage 2024 - English (PDF)

    Evidence of Coverage 2024 - Español (PDF)

    • Call us at ${MCA_MS_phone_1} or ${MCA_MS_phone_2} (TTY 711).
    • Call your provider.

     

     

    You don’t need approval to get emergency services. Not sure what’s an emergency? Read about emergency and urgent care.

     

    We expect our providers to follow certain guidelines when providing care to you. Need help understanding these guidelines, criteria or the info we used to make the PA decision? Just call ${MCA_MS_phone_1} or ${MCA_MS_phone_2} (TTY 711). 

    PA requests

    Routine requests for PA take up to 14 days for review. Here are some facts about routine requests:

    • If we need more info to approve the request, we may request another 14 days for review. You can file a Part C expedited grievance if you disagree with the time extension.
    • If we don’t get the info we requested from your provider, we’ll use the info we have to make a decision. If we deny the request, you’ll get a letter that explains your rights. 

    Urgent requests for PA take up to 72 hours for review. Here are some facts about urgent requests:

    • If your provider asks for an urgent PA but it doesn’t meet the criteria for urgent PA, we’ll process it as a routine request. 
    • We’ll send you a letter if we process your provider’s urgent request as a routine request. You can file a Part C expedited grievance if you disagree.

    Questions about whether your provider received PA for services? Call them or your clinical team. 

    Standard Prior Authorization form (PDF)

    Durable Medical Equipment (DME) Prior Authorization form (PDF)

    Therapy and Home Health Prior Authorization form (PDF)

    Not yet a member?

    Call Member Services at 602-586-1730 or 1-877-436-5288 (TTY 711). We’re here for you 8 a.m. to 8 p.m., 7 days a week.

    Referrals

    Referrals

    A referral is when your PCP sends you to a specialist provider for specific problems, like:

    • Skin disorders
    • Serious allergies 
    • Heart problems 

    A referral can also be to a lab or clinic. You may also ask for a second opinion from another network provider. A referral is valid through your entire treatment with the specialist.

    Self-referrals

    You don't need a referral from your PCP for:

    • Dental services
    • OB/GYN services
    • Behavioral health and substance use services
    • Emergency services

    H5580_25_065_C

    Questions?

    Call Member Services at ${MCA_MS_phone_1} or ${MCA_MS_phone_2} (TTY 711) We’re here for you ${MCA_MS_hours}.