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MORE INFORMATION.
For
a complete list of services that
do not require a referral, see
your Evidence of Coverage or
Member Handbook.
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Some services that do not require a referral:
»
Emergency services.
Alliance Medi-Cal Members may get the services below from any provider
that accepts Alliance Medi-Cal. All other Alliance Members must go to a
contracted provider in the Alliance’s service area.
»
Family planning services: includes pregnancy testing and birth control.
»
Sensitive services: includes testing and treatment of sexually transmitted
diseases and termination of pregnancy.
Alliance Medi-Cal members may get the services below from any OB-GYN
provider in the Alliance’s service area accepting Alliance Medi-Cal. All other
Alliance members must go to a contracted OB-GYN provider in the Alliance’s
service area.
»
Annual well-woman exam, Pap smear and breast exam.
»
Pregnancy services.
There are other services that do not require a referral. For more
information, see your Member Handbook or Evidence of Coverage.
This is called an
authorized
referral
. It is called this because we
have to authorize, or approve, the
referral before you can see the other
doctor.
If you are an Alliance Healthy Kids,
IHSS or Medi-Cal Access Program
member, you will need an authorized
referral if your PCP is referring you to
a doctor that is not contracted with
the Alliance—even one in our service
area.
Prior authorization.
The Alliance
has to approve some services,
procedures, medications and
equipment before you get
them. This is called
prior
authorization
. The provider
who is going to perform the
service must fill out a
request
for prior authorization
. The
provider sends it to us online,
by fax or by mail. We will review
the request and any medical
records the provider sends. If the
service, procedure, medication or
equipment is medically necessary
and a covered benefit, we will
approve the request. We will let the
provider know, and then you can
get the service. If we deny a request,
we will let you and the provider
know. You will be able to file a
complaint if you disagree with our
denial.
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healthy