Self-referrals are services you can arrange for yourself without first calling your 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, if you are eligible for dental services under the Medical Assistance program*
- Routine eye exams*
- Prescription eyeglasses for members under 21 years of age
- 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 $500 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 sends you to see a specialist, this is called a “referral.” In most cases, you will need to get a referral from your PCP to see a specialist. It may take a couple of days for your PCP to get the referral to the specialist. Always check with your PCP before going to see a specialist. For a list of services that do not need a referral, please see the self referrals section above.
Remember, there is a difference between a referral and a prescription. Examples:
- You would get a referral when you need to go to a specialist or outpatient facility. Your PCP will give you the referral.
- A prescription can come from any of your doctors or a nurse practitioner. You would need a prescription for things like medicine, equipment or special medical tests.
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.