Referrals and preapprovals in TX

Your primary care provider may want you to visit a specialist or another provider for care or services they can’t provide. You don’t need a referral from your primary care provider to get care from other providers in our plan. This includes behavioral health services, OB/GYN care, and family planning if these are benefits in your plan. It’s a good idea to talk to your primary care provider first about other types of care you may need. Your provider can tell you about other doctors in our plan and help you coordinate the care you receive.

You may need preapproval for a service

A preapproval is when your doctor asks us to approve a service before you receive it. Your provider will work with us to get the preapprovals you need.

Your provider will need to send in a preapproval request for:

Most surgeries, including some outpatient surgeries
All elective and nonurgent inpatient services and admissions
Chiropractic services
Most behavioral health and substance use disorder services (except routine outpatient and emergency services)
Certain prescriptions
Certain durable medical equipment, including prosthetics and orthotics
Certain gastroenterology procedures
Home health services
Hospice services
Rehabilitation therapy (physical, occupational, respiratory, and speech therapies)
Genetic testing
Sleep studies
Out-of-area or out-of-network care except in an emergency
Advanced imaging (tests such as MRAs, MRIs, CT scans, and CTA scans)
Certain pain management testing and procedures
Long-term services and supports