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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, 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.

PCP referrals

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.