Self-referrals are services you can arrange for yourself without first calling your primary care practitioner (PCP). You must see a Keystone First network provider for these self-referred services. Services that do not need a referral or prior authorization are:
- Prenatal visits.
- Routine obstetric (OB) care.
- Routine gynecological (GYN) care.
- Routine mammograms, with a prescription.
- Routine family planning services. **
- Routine dental services.
- Routine eye exams.*
- Prescription eyeglasses for members under age 21.
- Tobacco cessation counseling sessions.**
- First visit with a chiropractor.
- First 24 visits for outpatient physical, occupational, and speech therapy.
- Emergency services.**
- DME purchases costing less than $750 that are covered by the Medical Assistance program and with a prescription (see the prior authorization).
* You may need to get a referral or prior authorization from your PCP for some specialty care services. There may also be some limitations for self-referrals. If you are not sure if you need a referral from your PCP for a service, ask your PCP or call Member Services.
** This self-referred service may be provided by a provider not in the Keystone First network.
When your PCP thinks you need to see a specialist, he or she will refer you to a specialist who can best help you with your health care needs. To see the specialist, your PCP may need to send a referral form to that specialist. Or your PCP may need to give you a prescription to see the specialist. Ask your PCP if you will need a referral form or a prescription.
There are some specialist services you can get without seeing your PCP first. These specialists do not need a referral form or a prescription. Please see the section about self-referrals to find out which specialists you can go to without seeing your PCP first.
In some cases, members with a life-threatening, degenerative, or disabling disease or condition, or members with other special needs may be able to have a “standing referral.” A standing referral means you do not have to see your PCP each time you need to see a specialist. Call Member Services for more information.