Skip to Main content

Referrals

Self-referrals

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
  • 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.

PCP referrals

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.