Prior Authorization/Referral
How to Get Covered Services
Call your PCP when you need regular care. He or she will send you to see a specialist for tests, specialty care and other covered services that he or she doesn’t provide. Be sure your PCP approves you to see a specialist. If your PCP does not provide an approved service, ask him or her how you can get it.
Understanding Referrals and Prior Authorizations
Referrals
You may see any doctor in our network without a referral. However, some doctors may request a referral from your PCP. We will still cover medically necessary services provided by an in-network provider without a referral.
You may be referred to another provider if:
- Your PCP does not provide the care or service you need
- You need to see a specialist
You could be referred for medical tests, treatments or other services.
Referrals for certain care or services do not require our approval. These include:
- Routine diagnostic tests
- Lab tests
- Basic X-ray services
- Some routine care provided in a doctor’s office (not in a hospital)
Prior Authorizations (PAs)
Sometimes, your PCP or another provider may need to ask us to approve care before you get a service. This is called prior authorization (or PA for short). Your PCP or provider will contact us for this approval.
A PA is needed for these types of services:
- Rented or purchased medical supplies and equipment that costs more than $250
- Some medical tests done by your PCP or provider
- Cardiac and pulmonary rehabilitation programs
- Home health care
- Therapies (physical, occupational, speech)
- Inpatient and residential behavioral health services
This is not a complete list, and it may change from time to time. See your member handbook for a current list of services that require a PA.
If we do not approve a PA request, we’ll let you know. If we do not approve a PA request, and you still receive the service, the provider cannot bill you unless you agreed to pay for it in writing. If a PA is denied, you can ask for an appeal. If you still are not happy once the appeal is complete, you can ask for a State Fair Hearing. See your member handbook for more information.
Prior Authorization "How-To"
| Type of Request | Decision Time Frame | Who Can Request One |
|---|---|---|
Type of Request | Decision Time Frame | Who Can Request One |
Standard (for non-emergency care) | 2 business days* | Your provider |
Expedited/Fast** (for urgent care) | 24 hours** | Your provider |
*Sometimes we may need more time to make a standard decision. This may be because we need more information and it’s in your best interest. If so, we’ll take up to 14 more business days.
**Sometimes we may need more time to make a fast decision. If so, we’ll take up to 48 more hours.
Please note: PA decisions for services that have already been provided are made within 30 calendar days of us getting all needed information.
Services Available Without Authorization
You don’t need approval from us or your PCP for the following services:
- Direct access to in-network women’s health specialists for routine and preventive health care services
- Emergency/urgent care
- Family planning (any health plan provider)*
- Well-child visits for children age 20 or younger
- Routine vision care
- One women’s health visit to an OB/GYN provider each year
- Post-stabilization services
- Visits to your PCP
- Most outpatient behavioral health services (in-network)
Even though you don’t need approval for these services, you will need to see a provider in our network.
*Information about your family planning services will be kept private and, unless required by law, will not be shared with anyone without your approval, even if you are under the age of 18.
You can find a provider using our online provider search tool – Find a Provider. When you’ve made your choice, call to set up an appointment. Remember to take your ID cards with you.
| Services that Require a Prior Authorization | Prior Authorization Required for Some or All of the Services? |
|---|---|
| Advanced Radiology Services (CT, CTA, MRA, MRI, Nuclear Cardiology, Nuclear Medicine, PET & SPECT Scan) | Yes |
| Ambulatory Surgery Center | Some items require prior authorization |
| Bariatric Surgery (Certain restrictions and limitations may apply) | Yes |
| Cardiology Services (Cardiac Imaging, Cardiac Catheterization, Diagnostic Cardiac Procedures and Echo Stress Tests) | Yes |
| Dialysis | No |
| Durable Medical Equipment (DME) | Some items require prior authorization |
| Elective Inpatient Services | Yes |
| Emergency Services (Ambulance, Behavioral Health Services, Emergency Room Services, and Urgent Care Services) | No |
| Home Health Care Services | Yes |
| Hospice Admissions | Yes |
| Hospice Care Services | No |
| Hospital Services Inpatient | Yes |
| Hospital Services Outpatient | Some services require prior authorization |
| Investigational and Experimental Procedures and Treatment | Yes |
| Laboratory Services: All services necessary for the diagnosis, treatment and prevention of disease, and for the maintenance of health. | Yes- Some services require prior authorization |
| Long-Term Acute Care Hospital (LTACH) | Yes |
| Medical Oncology Services | Yes |
| Neonatal intensive care unit (NICU)/Sick Baby Admissions | Yes |
| Obstetric Global Care | Yes |
| Orthopedic Surgery | No |
| Orthotics & Prosthetics (O&P): Braces (non-dental) and other mechanical or molded devices to support or correct any defect of form or function of the human body. | Yes |
| Out of Network Provider Services | Yes |
| Outpatient Services | Yes |
| Oxygen & Respiratory Services | Some services require prior authorization |
| Pain Management | Yes |
| Prescribed Pediatric Extended Care | Yes |
| Radiation Therapy Management | Yes |
| Select Outpatient Procedures | Yes |
| Skilled Nursing Facility Admissions | Yes |
| Sleep Diagnostics | Yes |
| Spinal Therapy and/or Surgery | Yes |
| Sterilization Services | No |
| Substance Use Disorder Services | Some services require prior authorization |
Termination of Pregnancy | No |
| Therapy (OT, PT, ST) Services (Outpatient and including home based therapy) | Yes |
| Transplant Services | Yes |
All such services determined by Kentucky Medicaid to be medically necessary shall constitute a WellCare of Kentucky Covered Service. See the WellCare of Kentucky Member Handbook for more information on coverage out-of-network and out of the WellCare of Kentucky service area.
Documents and Resources
Notification of Pregnancy (PDF)
Do I need a referral to see a specialist?
No, you do not need a referral from your PCP to see a specialist. You do not need a referral for routine vision care, chiropractic services, or mental health/counseling services.