WV referrals and prior authorizations

A referral is when your primary care provider (PCP) sends you to another provider for care. You’ll need to talk with your PCP for a referral before you visit a specialist.

You’ll need to get a referral from your primary care provider (PCP) before:

• Meeting with a specialist.
• Going to a hospital for nonemergency care.
• Getting certain medicines, tests, medical equipment, and services.

For most care, you’ll go to your PCP or some other provider in our plan. These are called self-referral services. You don’t need a referral from your PCP for:

• Emergency care
• Preventive care services
• Family planning services
• Vision care
• Dental care
• Behavioral healthcare

We’ll also pay for some related lab work you’re prescribed at your self-referral service.

A prior authorization is when your provider asks us to approve a service before you receive it. Your provider will work with us to get the prior authorizations you need.

Your provider will need to send in a prior authorization for:

• Being admitted to the hospital or another facility.
• Some surgeries.
• Advanced imaging (CT, MRI, PET scans).
• Out-of-network care.
• Some durable medical equipment such as custom wheelchairs, breathing machines, or hospital beds.
• Certain behavioral health services such as residential treatment or psychological testing.