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    PA and referrals

    There are times when a child or youth in your care may need to see a specialist. Their primary care physician (PCP) will provide a referral. Some covered medical services may also need prior authorization (PA). This is an approval that happens beforehand to get special services your PCP or specialist want the child to have.

    Medical PA

    Medical 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 the PA list (PDF) to see if a service needs PA.
    • Contact us at ${MS_phone_1} or ${MS_phone_2} (TTY 711). We’re here for you ${MS_hours}.
    • Contact 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 us at ${MS_phone_1} or ${MS_phone_2} (TTY 711). We’re here for you ${MS_hours}.

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    PA requests and denials

    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 an appeal if you disagree with the time extension.
    • If we don’t receive the info we requested from your provider, we may deny the request for PA. If we deny it, we’ll send a letter to the DCS specialist or custodial agency representative 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 a letter to the DCS specialist or custodial agency representative if we process your provider’s urgent request as a routine request. 

    Questions about whether your service received PA? Call your provider or clinical team. 

    • If we deny PA, we’ll send a letter to the DCS specialist or custodial agency representative that explains your rights.
    • You can also file an appeal.

    Behavioral health PA

    Behavioral health PA

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

    • Non-emergency hospital stays
    • Behavioral health inpatient facilities 
    • Behavioral health residential (continued, longer-term stay) facilities
    • Home Care Training to Home Care Clients (HCTC) 
    • Non-emergency, out-of-network requests

    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 the PA list (PDF) to see if a service needs PA.
    • Contact us at ${MS_phone_1} or ${MS_phone_2} (TTY 711). We’re here for you ${MS_hours}.
    • Contact your provider

    You don’t need approval to get emergency services.

    Read More Read Less

    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 ask for another 14 days for review. You can file an appeal if you disagree with the time extension. If we don’t receive the info we requested from your provider, we may deny the request for PA. If we deny it, we’ll send a letter to the DCS specialist or custodial agency representative that explains your rights.
    • Routine requests for behavioral health residential facilities (BHRF) take up to 72 hours. We may extend this to 14 days for review if we need more info. You can file an appeal if you disagree with the time extension. If we don’t receive the info we requested from your provider, we may deny the request for PA. If we deny it, we’ll send a letter to the DCS specialist or custodial agency representative 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 a letter to the DCS specialist or custodial agency representative if we process your provider’s urgent request as a routine request. 

    Questions about whether your service received PA? Call your provider or clinical team.

    • If we deny PA, we’ll send a letter to the DCS specialist or custodial agency representative that explains your rights.
    • You can also file an appeal.

    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
    • Family-planning services
    • Emergency services
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    Questions?

    Call Member Services at ${MS_phone_1} or ${MS_phone_2}
    (TTY 711). We’re here for you ${member_services_hours}.